Sustained release drug delivery systems with reduced impurities and related methods

ABSTRACT

The present disclosure relates to sustained release drug delivery systems. In some cases, a composition comprises an active pharmaceutical agent; at least one of sucrose acetate isobutyrate and a polyorthoester; an organic solvent; and 2,6-dimethylaniline, wherein the 2,6-dimethylaniline is present at a level less than 500 ppm. In some cases, a composition comprises N-oxide of active pharmaceutical agent at a level less than 1 wt %, based on weight of the composition. In some case, a composition comprises metal present at a level less than 5 ppm. Dosage forms and methods are also provided.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application claims the benefit of priority to U.S. ProvisionalPatent Application Ser. No. 62/960,565 filed on Jan. 13, 2020, thedisclosure of which application is herein incorporated by reference.

TECHNICAL FIELD

The present disclosure relates generally to sustained release drugdelivery systems.

BACKGROUND

Biodegradable carriers for drug delivery are useful because they obviatethe need to remove the drug-depleted device. Examples of biodegradabledrug delivery systems include systems for controlled delivery of activepharmaceutical agents, e.g., local anesthetics, disclosed in U.S. Pat.Nos. 8,846,072 and 10,213,510, which are herein incorporated byreference in their entireties.

There remains, however, a need for improved drug delivery systems andmethods of administration and storage. For instance, there remains aneed for drug delivery systems having improved storage stability andsafety in use.

SUMMARY OF THE INVENTION

The inventors have determined that there also remains a need forsustained release delivery systems containing low amounts of impurities,such as 2,6-dimethylaniline, bupivacaine N-oxide, water, peroxide,benzyl acetate, benzyl isobutyrate, and/or low amounts of metal.

The present disclosure provides improved drug delivery systems havingreduced impurities. The present disclosure provides improved drugdelivery systems having improved stability and/or safety. Other featuresand advantages of the present invention will be set forth in thedescription of invention that follows, and in part will be apparent fromthe description or may be learned by practice of the invention. Theinvention will be realized and attained by the compositions and methodsparticularly pointed out in the written description and claims hereof.

The following numbered aspects, while non-limiting, are exemplary ofcertain aspects of the present disclosure:

1. A composition comprising:

an active pharmaceutical agent;

at least one of a high viscosity liquid carrier material (HVLCM) and apolyorthoester;

an organic solvent; and

2,6-dimethylaniline,

wherein the 2,6-dimethylaniline is present in the composition at a levelless than 500 ppm.

2. The composition of aspect 1, wherein the 2,6-dimethylaniline ispresent in the composition at a level less than 300 ppm.3. The composition of aspect 1, wherein the 2,6-dimethylaniline ispresent in the composition at a level less than 200 ppm.4. The composition of aspect 1, wherein the 2,6-dimethylaniline ispresent in the composition at a level less than 100 ppm.5. The composition of aspect 1, wherein the 2,6-dimethylaniline ispresent in the composition at a level less than 15 ppm, less than 12ppm, less than 10 ppm, or less than 5 ppm.6. The composition of aspect 1, wherein the 2,6-dimethylaniline ispresent in the composition at a level ranging from 0.2 ppm to 500 ppm.7. The composition of aspect 1, wherein the 2,6-dimethylaniline ispresent in the composition at a level ranging from 0.3 ppm to 200 ppm.8. The composition of aspect 1, wherein the 2,6-dimethylaniline ispresent in the composition at a level ranging from 0.4 ppm to 100 ppm.9. The composition of aspect 1, wherein the 2,6-dimethylaniline ispresent in the composition at a level ranging from 0.5 ppm to 10 ppm or2 ppm to 8 ppm.10. A composition comprising:

an active pharmaceutical agent;

at least one of a high viscosity liquid carrier material (HVLCM) and apolyorthoester;

an organic solvent; and

N-oxide of the active pharmaceutical agent,

wherein the N-oxide of the active pharmaceutical agent is present in thecomposition at a level less than 1 wt %, based on weight of thecomposition.

11. The composition of aspect 10, wherein the N-oxide of the activepharmaceutical agent is present in the composition at a level less than0.7 wt % or less than 0.5 wt %, based on weight of the composition.12. The composition of aspect 10, wherein the N-oxide of the activepharmaceutical agent is present in the composition at a level less than0.4 wt %, based on weight of the composition.13. The composition of aspect 10, wherein the N-oxide of the activepharmaceutical agent is present in the composition at a level rangingfrom 0.01 wt % to 1 wt %, based on weight of the composition.14. The composition of aspect 10, wherein the N-oxide of the activepharmaceutical agent is present in the composition at a level rangingfrom 0.05 wt % to 0.4 wt % or 0.1 wt % to 0.4 wt %, based on weight ofthe composition.15. The composition of aspect 10, wherein the N-oxide of the activepharmaceutical agent is present in the composition at a level rangingfrom 0.1 wt % to 0.2 wt %, based on weight of the composition.16. A composition comprising:

an active pharmaceutical agent;

at least one of a high viscosity liquid carrier material (HVLCM) and apolyorthoester;

an organic solvent; and

a metal,

wherein the metal is present in the composition at a level less than 5ppm.

17. The composition of aspect 16, wherein the metal is present in thecomposition at a level less than 4 ppm.18. The composition of aspect 16, wherein the metal is present in thecomposition at a level less than 3 ppm.19. The composition of aspect 16, wherein the metal is present in thecomposition at a level ranging from 0.01 ppm to 4 ppm.20. The composition of aspect 16, wherein the metal is present in thecomposition at a level ranging from 0.05 ppm to 3 ppm.21. The composition of aspect 16, wherein the metal is present in thecomposition at a level ranging from 0.1 ppm to 2 ppm.22. A composition comprising:

an active pharmaceutical agent;

at least one of a high viscosity liquid carrier material (HVLCM) and apolyorthoester;

an organic solvent; and

water,

wherein the water is present at a level less than 0.5 wt %, based onweight of the composition.

23. The composition of aspect 22, wherein the water is present in thecomposition at a level less than 0.4 wt %, based on weight of thecomposition.24. The composition of aspect 22, wherein the water is present in thecomposition at a level less than 0.3 wt %, based on weight of thecomposition.25. The composition of aspect 22, wherein the water is present in thecomposition at a level ranging from 0.03 wt % to 0.4 wt %, based onweight of the composition.26. The composition of aspect 22, wherein the water is present in thecomposition at a level ranging from 0.05 wt % to 0.35 wt %, based onweight of the composition.27. The composition of aspect 22, wherein the water is present in thecomposition at a level ranging from 0.08 wt % to 0.3 wt %, based onweight of the composition.28. A composition comprising:

an active pharmaceutical agent;

a high viscosity liquid carrier material (HVLCM) comprising sucroseacetate isobutyrate;

an organic solvent comprising benzyl alcohol; and

benzyl acetate,

wherein the benzyl acetate is present in the composition at a level lessthan 100 mg/mL.

29. The composition of aspect 28, wherein the benzyl acetate is presentin the composition at a level less than 50 mg/mL.30. The composition of aspect 28, wherein the benzyl acetate is presentin the composition at a level less than 20 mg/mL or less than 15 mg/mL.31. The composition of aspect 28, wherein the benzyl acetate is presentin the composition at a level ranging from 0.1 mg/mL to 80 mg/mL.32. The composition of aspect 28, wherein the benzyl acetate is presentin the composition at a level ranging from 0.5 mg/mL to 40 mg/mL.33. The composition of aspect 28, wherein the benzyl acetate is presentin the composition at a level ranging from 1 mg/mL to 20 mg/mL or 1mg/mL to 15 mg/mL.34. A composition comprising:

an active pharmaceutical agent;

a high viscosity liquid carrier material (HVLCM) comprising sucroseacetate isobutyrate;

an organic solvent comprising benzyl alcohol; and

benzyl isobutyrate,

wherein the benzyl isobutyrate is present in the composition at a levelless than 50 mg/mL.

35. The composition of aspect 34, wherein the benzyl isobutyrate ispresent in the composition at a level less than 30 mg/mL.36. The composition of aspect 34, wherein the benzyl isobutyrate ispresent in the composition at a level less than 10 mg/mL or less than 8mg/mL.37. The composition of aspect 34, wherein the benzyl isobutyrate ispresent in the composition at a level ranging from 0.1 mg/mL to 40mg/mL.38. The composition of aspect 34, wherein the benzyl isobutyrate ispresent in the composition at a level ranging from 0.5 mg/mL to 30mg/mL.39. The composition of aspect 34, wherein the benzyl isobutyrate ispresent in the composition at a level ranging from 1 mg/mL to 10 mg/mLor 1 mg/mL to 8 mg/mL.40. A composition made by combining:

an active pharmaceutical agent;

a high viscosity liquid carrier material (HVLCM) comprising sucroseacetate isobutyrate having peroxide that is present at a level less than200 ppm; and

an organic solvent.

41. The composition of aspect 40, wherein the sucrose acetateisobutyrate has peroxide that is present at a level less than 100 ppm.42. The composition of aspect 40, wherein the sucrose acetateisobutyrate has peroxide that is present at a level less than 80 ppm orless than 60 ppm.43. The composition of aspect 40, wherein the sucrose acetateisobutyrate has peroxide that is present at a level ranging from 1 ppmto 100 ppm.44. The composition of aspect 40, wherein the sucrose acetateisobutyrate has peroxide that is present at a level ranging from 2 ppmto 80 ppm.45. The composition of aspect 40, wherein the sucrose acetateisobutyrate has peroxide that is present at a level ranging from 3 ppmto 60 ppm.46. A composition made by combining:

an active pharmaceutical agent;

at least one of a high viscosity liquid carrier material (HVLCM) and apolyorthoester; and

an organic solvent having peroxide that is present at a level less than100 ppm, the organic solvent optionally comprising at least one ofbenzyl alcohol, dimethyl sulfoxide, and triacetin.

47. The composition of aspect 46, wherein the organic solvent hasperoxide that is present at a level less than 85 ppm.48. The composition of aspect 46, wherein the organic solvent hasperoxide that is present at a level less than 10 ppm.49. The composition of aspect 46, wherein the organic solvent hasperoxide that is present at a level ranging from 1 ppm to 90 ppm.50. The composition of aspect 46, wherein the organic solvent hasperoxide that is present at a level ranging from 2 ppm to 85 ppm.51. The composition of aspect 46, wherein the organic solvent hasperoxide present at a level ranging from 3 ppm to 10 ppm.52. A composition comprising:

an active pharmaceutical agent;

a high viscosity liquid carrier material (HVLCM) comprising sucroseacetate isobutyrate present at a level ranging from 30 wt % to 80 wt %,based on weight of the composition; and

an organic solvent.

53. The composition of aspect 52, wherein the sucrose acetateisobutyrate is present in the composition at a level ranging from 40 wt% to 70 wt %, 50 wt % to 70 wt %, 60 wt % to 70 wt %, 61 wt % to 69 wt%, based on weight of the composition.54. The composition of aspect 52, wherein the sucrose acetateisobutyrate is present in the composition at a level ranging from 62 wt% to 68 wt %, based on weight of the composition.55. The composition of aspect 52, wherein the sucrose acetateisobutyrate is present in the composition at a level ranging from 63 wt% to 67 wt %, based on weight of the composition.56. A composition comprising:

an active pharmaceutical agent;

at least one of a high viscosity liquid carrier material (HVLCM) and apolyorthoester, the HVLCM optionally comprising sucrose acetateisobutyrate present at a level ranging from 30 wt % to 80 wt %, based onweight of the composition, and optionally the composition is preparedusing sucrose acetate isobutyrate having peroxide that is present at alevel less than 200 ppm;

an organic solvent, the organic solvent optionally comprising at leastone of benzyl alcohol, dimethyl sulfoxide, and triacetin, and optionallythe composition is prepared using organic solvent having peroxide thatis present at a level less than 100 ppm; and

at least one of:

-   -   2,6-dimethylaniline, wherein the 2,6-dimethylaniline is present        in the composition at a level less than 500 ppm,    -   N-oxide of the active pharmaceutical agent, wherein the N-oxide        of the active pharmaceutical agent is present in the composition        at a level less than 1 wt %, based on weight of the composition,    -   a metal, wherein the metal is present in the composition at a        level less than 5 ppm,    -   water, wherein the water is present at a level less than 0.5 wt        %, based on weight of the composition,    -   benzyl acetate, wherein the benzyl acetate is present in the        composition at a level less than 100 mg/mL, and    -   benzyl isobutyrate, wherein the benzyl isobutyrate is present in        the composition at a level less than 50 mg/mL.        57. The composition of any one of aspects 1 to 56, wherein the        active pharmaceutical agent comprises a local anesthetic.        58. The composition of any one of aspects 1 to 56, wherein the        active pharmaceutical agent comprises at least one member        selected from bupivacaine, lidocaine, ropivacaine, etidocaine,        mepivacaine, pyrrocaine, and salts thereof.        59. The composition of any one of aspects 1 to 56, wherein the        active pharmaceutical agent comprises bupivacaine or a salt        thereof.        60. The composition of any one of aspects 1 to 59, wherein the        active pharmaceutical agent is present in the composition in an        amount ranging from 1 wt % to 25 wt %, based on weight of the        composition.        61. The composition of any one of aspects 1 to 59, wherein the        active pharmaceutical agent is present in the composition in an        amount ranging from 5 wt % to 20 wt %, based on weight of the        composition.        62. The composition of any one of aspects 1 to 59, wherein the        active pharmaceutical agent is present in the composition in an        amount ranging from 10 wt % to 15 wt %, based on weight of the        composition.        63. The composition of any one of aspects 1 to 59, wherein the        active pharmaceutical agent is present in the composition in an        amount of about 12 wt %, based on weight of the composition.        64. The composition of any one of aspects 1 to 63, wherein the        organic solvent comprises at least one member selected from        benzyl alcohol, benzyl benzoate, dimethylsulfoxide, ethanol,        N-methylpyrrolidone, and triacetin.        65. The composition of any one of aspects 1 to 63, wherein the        organic solvent comprises benzyl alcohol.        66. The composition of any one of aspects 1 to 63, wherein the        organic solvent comprises triacetin.        67. The composition of any one of aspects 1 to 63, wherein the        organic solvent comprises dimethylsulfoxide.        68. The composition of any one of aspects 1 to 67, wherein the        organic solvent is present in the composition in an amount        sufficient to dissolve the active pharmaceutical agent in the        composition, or the organic solvent is present in the        composition in an amount of at least 5 wt %, based on weight of        the composition.        69. The composition of any one of aspects 1 to 68, wherein the        organic solvent is present in the composition in an amount of at        least 10 wt %, based on weight of the composition.        70. The composition of any one of aspects 1 to 68, wherein the        organic solvent is present in the composition in an amount of at        least 15 wt %, based on weight of the composition.        71. The composition of any one of aspects 1 to 68, wherein the        organic solvent is present in the composition in an amount of at        least 20 wt %, based on weight of the composition.        72. The composition of any one of aspects 1 to 68, wherein the        organic solvent is present in the composition in an amount        ranging from 5 wt % to 45 wt %, based on weight of the        composition.        73. The composition of any one of aspects 1 to 68, wherein the        organic solvent is present in the composition in an amount        ranging from 10 wt % to 35 wt %, based on weight of the        composition.        74. The composition of any one of aspects 1 to 68, wherein the        organic solvent is present in the composition in an amount        ranging from 15 wt % to 30 wt %, based on weight of the        composition.        75. The composition of any one of aspects 1 to 68, wherein the        organic solvent is present in the composition in an amount        ranging from 20 wt % to 25 wt %, based on weight of the        composition.        76. The composition of any one of aspects 1 to 68, wherein the        organic solvent is present in the composition in an amount of        about 22 wt %, based on weight of the composition.        77. The composition of any one of aspects 1 to 76, wherein the        composition comprises HVLCM comprising sucrose acetate        isobutyrate.        78. The composition of any one of aspects 1 to 76, wherein the        composition comprises HVLCM present in the composition in an        amount sufficient to provide sustained release of the active        pharmaceutical agent from the composition, such as sustained        release of about 72 hours, or the composition comprises HVLCM        present in the composition in an amount ranging from 50 wt % to        80 wt %, based on weight of the composition.        79. The composition of any one of aspects 1 to 76, wherein the        composition comprises HVLCM present in the composition in an        amount ranging from 55 wt % to 75 wt %, based on weight of the        composition.        80. The composition of any one of aspects 1 to 76, wherein the        composition comprises HVLCM present in the composition in an        amount ranging from 60 wt % to 70 wt %, based on weight of the        composition.        81. The composition of any one of aspects 1 to 76, wherein the        composition comprises HVLCM present in the composition in an        amount of about 66 wt %, based on weight of the composition.        82. The composition of any one of aspects 1 to 81, wherein the        composition comprises polyorthoester.        83. The composition of any one of aspects 1 to 81, wherein the        composition comprises polyorthoester having a weight average        molecular weight ranging from 1000 Daltons to 10,000 Daltons.        84. The composition of any one of aspects 1 to 81, wherein the        composition comprises polyorthoester present in an amount        ranging from 40 wt % to 70 wt %, based on weight of the        composition.        85. The composition of any one of aspects 1 to 84, further        comprising meloxicam.        86. The composition of any one of aspects 1 to 85, wherein the        composition has been stored at a temperature ranging from 15° C.        to 30° C.        87. The composition of any one of aspects 1 to 85, wherein the        composition has been stored at a temperature ranging from 20° C.        to 25° C. 88. The composition of any one of aspects 1 to 9 and        56 to 87, wherein when the composition is stored in a sealed,        upright, clear glass vial at 25° C./60% RH for 20 months, the        2,6-dimethylaniline is present at the level, e.g., when the        composition is stored in a sealed, upright, clear glass vial at        25° C./60% RH for 20 months, the 2,6-dimethylaniline may be        present at a level less than 500 ppm.        89. The composition of any one of aspects 1 to 9 and 56 to 87,        wherein when the composition is stored in a sealed, upright,        clear glass vial at 25° C./60% RH for 36 months, the        2,6-dimethylaniline is present at the level.        90. The composition of any one of aspects 1 to 9 and 56 to 87,        wherein when the composition is stored in a sealed, upright,        clear glass vial at 40° C./75% RH for 20 months, the        2,6-dimethylaniline is present at the level.        91. The composition of any one of aspects 1 to 9 and 56 to 87,        wherein when the composition is stored in a sealed, upright,        clear glass vial at 40° C./75% RH for 36 months, the        2,6-dimethylaniline is present at the level.        92. The composition of any one of aspects 10 to 15 and 56 to 87,        wherein when the composition is stored in a sealed, upright,        clear glass vial at 25° C./60% RH for 20 months, the N-oxide of        the active pharmaceutical agent is present at the level.        93. The composition of any one of aspects 10 to 15 and 56 to 87,        wherein when the composition is stored in a sealed, upright,        clear glass vial at 25° C./60% RH for 36 months, the N-oxide of        the active pharmaceutical agent is present at the level.        94. The composition of any one of aspects 10 to 15 and 56 to 87,        wherein when the composition is stored in a sealed, upright,        clear glass vial at 40° C./75% RH for 20 months, the N-oxide of        the active pharmaceutical agent is present at the level.        95. The composition of any one of aspects 10 to 15 and 56 to 87,        wherein when the composition is stored in a sealed, upright,        clear glass vial at 40° C./75% RH for 36 months, the N-oxide of        the active pharmaceutical agent is present at the level.        96. The composition of any one of aspects 16 to 21 and 56 to 87,        wherein when the composition is stored in a sealed, upright,        clear glass vial at 25° C./60% RH for 20 months, the metal is        present at the level.        97. The composition of any one of aspects 16 to 21 and 56 to 87,        wherein when the composition is stored in a sealed, upright,        clear glass vial at 25° C./60% RH for 36 months, the metal is        present at the level.        98. The composition of any one of aspects 16 to 21 and 56 to 87,        wherein when the composition is stored in a sealed, upright,        clear glass vial at 40° C./75% RH for 20 months, the metal is        present at the level.        99. The composition of any one of aspects 16 to 21 and 56 to 87,        wherein when the composition is stored in a sealed, upright,        clear glass vial at 40° C./75% RH for 36 months, the metal is        present at the level.        100. The composition of any one of aspects 22 to 27 and 56 to        87, wherein when the composition is stored in a sealed, upright,        clear glass vial at 25° C./60% RH for 20 months, the water is        present at the level.        101. The composition of any one of aspects 22 to 27 and 56 to        87, wherein when the composition is stored in a sealed, upright,        clear glass vial at 25° C./60% RH for 36 months, the water is        present at the level.        102. The composition of any one of aspects 22 to 27 and 56 to        87, wherein when the composition is stored in a sealed, upright,        clear glass vial at 40° C./75% RH for 20 months, the water is        present at the level.        103. The composition of any one of aspects 22 to 27 and 56 to        87, wherein when the composition is stored in a sealed, upright,        clear glass vial at 40° C./75% RH for 36 months, the water is        present at the level.        104. The composition of any one of aspects 28 to 33 and 56 to        87, wherein when the composition is stored in a sealed, upright,        clear glass vial at 25° C./60% RH for 20 months, the benzyl        acetate is present at the level.        105. The composition of any one of aspects 28 to 33 and 56 to        87, wherein when the composition is stored in a sealed, upright,        clear glass vial at 25° C./60% RH for 36 months, the benzyl        acetate is present at the level.        106. The composition of any one of aspects 28 to 33 and 56 to        87, wherein when the composition is stored in a sealed, upright,        clear glass vial at 40° C./75% RH for 20 months, the benzyl        acetate is present at the level.        107. The composition of any one of aspects 28 to 33 and 56 to        87, wherein when the composition is stored in a sealed, upright,        clear glass vial at 40° C./75% RH for 36 months, the benzyl        acetate is present at the level.        108. The composition of any one of aspects 34 to 39 and 56 to        87, wherein when the composition is stored in a sealed, upright,        clear glass vial at 25° C./60% RH for 20 months, the benzyl        isobutyrate is present at the level.        109. The composition of any one of aspects 34 to 39 and 56 to        87, wherein when the composition is stored in a sealed, upright,        clear glass vial at 25° C./60% RH for 36 months, the benzyl        isobutyrate is present at the level.        110. The composition of any one of aspects 34 to 39 and 56 to        87, wherein when the composition is stored in a sealed, upright,        clear glass vial at 40° C./75% RH for 20 months, the benzyl        isobutyrate is present at the level.        111. The composition of any one of aspects 34 to 39 and 56 to        87, wherein when the composition is stored in a sealed, upright,        clear glass vial at 40° C./75% RH for 36 months, the benzyl        isobutyrate is present at the level.        112. The composition of any one of aspects 52 to 87, wherein        when the composition is stored in a sealed, upright, clear glass        vial at 25° C./60% RH for 20 months, the sucrose acetate        isobutyrate is present at the level.        113. The composition of any one of aspects 52 to 87, wherein        when the composition is stored in a sealed, upright, clear glass        vial at 25° C./60% RH for 36 months, the sucrose acetate        isobutyrate is present at the level.        114. The composition of any one of aspects 52 to 87, wherein        when the composition is stored in a sealed, upright, clear glass        vial at 40° C./75% RH for 20 months, the sucrose acetate        isobutyrate is present at the level.        115. The composition of any one of aspects 52 to 87, wherein        when the composition is stored in a sealed, upright, clear glass        vial at 40° C./75% RH for 36 months, the sucrose acetate        isobutyrate is present at the level.        116. A dosage system comprising:

a container comprising a first inert material;

a closure capable of closing the container, the closure comprising asecond inert material; and

the composition of any one of aspects 1 to 115 contained within thecontainer.

117. The dosage system of aspect 116, wherein the dosage system does notinclude silicone oil.118. The dosage system of any one of aspects 116 and 117, wherein thesecond inert material comprises a fluorocarbon.119. The dosage system of any one of aspects 116 to 118, wherein thesecond inert material comprises tetrafluoroethylene.120. The dosage system of any one of aspects 116 to 119, wherein thesecond inert material comprises a fluorinated polymer.121. The dosage system of any one of aspects 116 to 120, wherein theclosure comprises a fluorocarbon-coated stopper.122. The dosage system of any one of aspects 110 to 121, wherein thefirst inert material comprises glass.123. The dosage system of aspect 122, wherein the glass comprises clearglass.124. The dosage system of any one of aspects 122 and 123, wherein theglass is transparent to visible light.125. The dosage system of any one of aspects 122 to 124, wherein theglass has an optical density of 1 or less to wavelengths of light offrom 400 nm to 600 nm.126. The dosage system of any one of aspects 122 to 125, wherein theglass has an optical density of greater than 1 to wavelengths of lightof from 100 nm to 250 nm.127. The dosage system of any one of aspects 122 to 126, wherein theglass does not contain iron.128. The dosage system of any one of aspects 122 to 126, wherein theglass comprises borosilicate glass that does not contain iron.129. The dosage system of any one of aspects 122 to 128, wherein theglass comprises pyrex glass that does not contain iron.130. The dosage system of any one of aspects 116 to 129, wherein thecontainer comprises a vial.131. A dosage system comprising:

a first container;

a second container within the first container, the second containercomprising a first inert material and the first container reducesambient visible light from irradiating onto the second container; and

the composition of any one of aspects 1 to 115 within the secondcontainer.

132. The dosage system of aspect 131, wherein the first containercomprises a box or a carton, optionally the first container is a 1-unitto 25-unit box or carton, such as a 10-unit box or carton, optionallyten of the second containers are in the first container, optionally thefirst container is in a second box.133. The dosage system of any one of aspects 131 and 132, wherein thefirst container comprises a polymer.134. The dosage system of any one of aspects 131 to 133, wherein thefirst container comprises a thermoplastic.135. The dosage system of any one of aspects 131 to 134, wherein thefirst container comprises cellulose.136. The dosage system of any one of aspects 131 to 135, wherein thefirst container comprises clay.137. The dosage system of any one of aspects 131 to 136, wherein thefirst container comprises a material having a thickness of at least 0.5mm or ranging from 0.4 mm to 3 mm, such as 0.5 mm to 2.5 mm, 0.5 mm to 1mm, 0.6 mm to 0.9 mm, or 0.7 mm to 0.8 mm.138. The dosage system of any one of aspects 116 to 137, furthercomprising a gas contained within the container that contains thecomposition, the gas having an oxygen content of less than 10 mol % orless than 10 wt %.139. The dosage system of aspect 138, wherein the gas has an oxygencontent ranging from 1 mol % to 10 mol % or 1 wt % to 10 wt %.140. The dosage system of aspect 138, wherein the gas fills a headspacewithin the container that contains the composition.141. The dosage system of any one of aspects 116 to 140, wherein thecontainer that contains the composition comprises a layer that reduceslight transmission.142. A process comprising:

filtering the composition of any one of aspects 1 to 115; and

aseptically processing the composition.

143. The process of aspect 142, wherein the filtering comprises heatingthe composition to 25° C. to 50° C.144. The process of aspect 142, wherein the filtering comprises heatingthe composition to 25° C. to 45° C.145. The process of aspect 142, wherein the filtering comprises heatingthe composition to 30° C. to 35° C.146. The process of any one of aspects 142 to 145, wherein theaseptically processing comprises filling the composition into acontainer.147. The process of any one of aspects 146, wherein the filling isconducted under an atmosphere comprising an inert gas.148. The process of aspect 147, wherein the inert gas comprises at leastone member selected from nitrogen, helium, neon, argon, kryptonr xenon,and carbon dioxide.149. The process of aspect 147, wherein the inert gas comprisesnitrogen.150. The process of any one of aspect 142 to 149, wherein asepticallyprocessing the composition comprises preparing a dosage systemcomprising: a container comprising a first inert material; a closure forclosing the container, the closure comprising a second inert material;and the composition contained within the container; the processcomprising filling the composition into the container.151. The process of aspect 150, wherein the dosage system does notinclude silicone oil.152. The process of any one of aspects 150 and 151, wherein the secondinert material comprises a fluorocarbon.153. The process of any one of aspects 150 to 152, wherein the secondinert material comprises tetrafluoroethylene.154. The process of any one of aspects 150 to 153, wherein the secondinert material comprises a fluorinated polymer.155. The process of any one of aspects 150 to 154, wherein the closurecomprises a fluorocarbon-coated stopper.158. The process of any one of aspects 156 and 157, wherein the glass istransparent to visible light.159. The process of any one of aspects 156 to 158, wherein the glass hasan optical density of 1 or less to wavelengths of light of from 400 nmto 600 nm.160. The process of any one of aspects 156 to 159, wherein the glass hasan optical density of greater than 1 to wavelengths of light of from 100nm to 250 nm.161. The process of any one of aspects 156 to 160, wherein the glassdoes not contain iron.162. The process of any one of aspects 156 to 161, wherein the glasscomprises borosilicate glass that does not contain iron.163. The process of any one of aspects 156 to 162, wherein the glasscomprises pyrex glass that does not contain iron.164. The process of any one of aspects 150 to 163, wherein the containercomprises a vial.165. The process of any one of aspect 142 to 149, wherein asepticallyprocessing the composition comprises preparing a dosage systemcomprising: a first container; a second container within the firstcontainer, the second container comprising a first inert material andthe first container preventing ambient visible light from irradiatingonto the second container; and the composition within the secondcontainer; the process comprising filling the composition into thesecond container.166. The process of aspect 165, wherein the first container comprises abox.167. The process of any one of aspects 165 and 166, wherein the firstcontainer comprises a polymer.168. The process of any one of aspects 165 to 167, wherein the firstcontainer comprises a thermoplastic.169. The process of any one of aspects 165 to 168, wherein the firstcontainer comprises cellulose.170. The process of any one of aspects 165 to 168, wherein the firstcontainer comprises clay.171. The process of any one of aspects 165 to 170, wherein the firstcontainer has a thickness of at least 0.5 mm.172. The process of any one of aspects 150 to 171, further comprising agas contained within the container that contains the composition, thegas having an oxygen content of less than 10 mol % or less than 10 wt %.173. The process of aspect 172, wherein the gas has an oxygen contentranging from 1 mol % to 10 mol % or 1 wt % to 10 wt %.174. The process of aspect 172, wherein the gas fills a headspace withinthe container that contains the composition.175. The process of any one of aspects 150 to 172, wherein the containerthat contains the composition comprises a layer that reduces lighttransmission.176. A method of treating or prophylactically treating pain, comprisingadministering an effective amount of the composition of any one ofaspects 1 to 175 to a subject in need thereof.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 shows the water content and coloration of Formulation A samples.

FIG. 2 shows a linear regression line fitted to the SAIB peroxidecontent data versus bupivacaine N-oxide levels.

FIG. 3 shows label strength of 4 primary (5 mL) and 4 secondary (7.5 mL)lots of samples of Formulation A over a 36-month period.

FIG. 4 shows change in bupivacaine N-oxide (measure in % bupivacaineN-oxide) in 4 primary (5 mL) and 4 secondary (7.5 mL) lots of samples ofFormulation A over a 36-month period.

FIG. 5 shows presence of 2,6-dimethylaniline (measure in ppm) in 4primary (5 mL) and 4 secondary (7.5 mL) lots of samples of Formulation Aover an 18-month period (months 18-36).

FIG. 6 shows presence of 2,6-dimethylaniline in samples of Formulation Astored for a 6-month period at 3 different temperatures (25° C., 30° C.and 40° C.) and 2 different relative humidities (60% RH, 75% RH).

FIG. 7 shows presence of benzyl acetate (measure in mg/mL) in 4 primary(5 mL) and 4 secondary (7.5 mL) lots of samples of Formulation A over a36-month period.

FIG. 8 shows presence of benzyl acetate in samples of Formulation Astored for a 6-month period at 3 different temperatures (25° C., 30° C.and 40° C.) and 2 different relative humidities (60% RH, 75% RH).

FIG. 9 shows presence of benzyl isobutyrate (measure in mg/mL) in 4primary (5 mL) and 4 secondary (7.5 mL) lots of samples of Formulation Aover a 36-month period.

FIG. 10 shows presence of benzyl isobutyrate in samples of Formulation Astored for a 6-month period at 3 different temperatures (25° C., 30° C.and 40° C.) and 2 different relative humidities (60% RH, 75% RH).

FIG. 11 shows change in percent SAIB in 4 primary (5 mL) and 4 secondary(7.5 mL) lots of samples of Formulation A over a 36-month period.

FIG. 12 shows mean cumulative release of a control formulation (N=4),−30% SAIB formulation (N=3), −40% SAB formulation (N=3), −50% SAIBformulation (N=4), −70% SAIB formulation (N=3), and −90% SAIBformulation (N=3).

FIG. 13 shows mean cumulative release of a control formulation (N=12),+20% SAB formulation (N=12), −20% SAB formulation (N=12), and −70% SABformulation (N=12).

FIG. 14 shows mean cumulative release of a control formulation (N=12)and heat-stressed SAB formulation (N=12).

FIG. 15 shows pain intensity (PI) on movement over time for theintent-to-treat (ITT) population.

FIG. 16 shows geometric mean total and free bupivacaine plasmaconcentration following bupivacaine concentration followingadministration of Formulation A or standard bupivacaine.

FIG. 17 shows a correlation of all individual plasma concentrations offree versus total bupivacaine for Formulation A.

FIG. 18 shows pain intensity normalized AUC was compared betweentreatment groups using ANCOVA with treatment group and trial site asfactors and age as a covariate.

FIG. 19A shows the mean pain intensity on movement by subjects in themodified intent-to-treat (MITT) set administered Formulation A ascompared to subjects administered placebo at time points post dose.

FIG. 19B depicts the mean pain intensity on movement by subjects in theper protocol (PP) set administered Formulation A as compared to subjectsadministered placebo at time points post dose.

FIG. 20 shows cumulative morphine equivalent dose compared betweentreatment groups using ANCOVA with treatment group and trial site asfactors and age as a covariate.

FIG. 21 depicts the cumulative morphine equivalent dose in the MITT setadministered Formulation A as compared to subjects administered placeboat time points post dose.

FIG. 22 shows mean PI_(move) over time, analyzed separately for Cohort 1and Cohort 2.

FIG. 23 shows PI_(move) over time in a subgroup of subjects who hadminimal or no glenohumeral pathology.

FIGS. 24 to 26 show line graphs of mean pain intensity onmovement±standard error of the mean (SEM) versus the scheduled time ofpain assessment for each cohort.

FIGS. 27 to 29 show graphs of plasma bupivacaine concentration vs. timeafter treatment.

FIG. 30 shows that release from a PLGA composition showed morevariability than release from a POE composition as shown by the largererror bars (standard deviation).

FIG. 31 also shows larger variability in release from a PLGA compositionthan from a POE composition, which shows the individual release profilesfor each of the six replicates of each formulation.

DETAILED DESCRIPTION

Before describing the present invention in detail, it is to beunderstood that this invention is not limited to particularlyexemplified carrier materials or process parameters as such may, ofcourse, vary. It is also to be understood that the terminology usedherein is for the purpose of describing particular embodiments of theinvention only, and is not intended to be limiting.

All publications, patents and patent applications cited herein, whethersupra or infra, are hereby incorporated by reference in their entirety.

It must be noted that, as used in this specification and the appendedclaims, the singular forms “a,” “an” and “the” include plural referentsunless the content clearly dictates otherwise. Thus, for example, “asolvent” includes a mixture of two or more such carriers, reference to“an anesthetic” includes mixtures of two or more such agents, and thelike.

As used herein, “present” at a level means that a given component, e.g.,2,6-dimethylaniline, is present at a level greater than zero.

The present disclosure relates to a plurality of strategies to improvestability and safety of sustained release drug delivery formulations.The strategies include improved sterilization, prevention of lightinduced degradation, and inert container closures, and low metalcontent.

In some aspects, the present disclosure relates to sustained releasedrug delivery formulations having low amounts of 2,6-dimethylaniline(Formula I):

In some cases, the 2,6-dimethylaniline is present in the drug deliveryformulation at a level less than 500 ppm, such as less than 300 ppm,less than 200 ppm, less than 100 ppm, less than 15 ppm, less than 12ppm, less than 10 ppm, or less than 5 ppm. In some cases, the2,6-dimethylaniline is present in the drug delivery formulation at alevel ranging from 0.2 ppm to 500 ppm, such as from 0.3 ppm to 200 ppm,from 0.4 ppm to 100 ppm, from 0.5 ppm to 10 ppm, or 2 ppm to 8 ppm.

In some cases, the present disclosure relates to compositions having lowamounts of N-oxide of the active pharmaceutical agent. For instance, theN-oxide of the active pharmaceutical agent may be present in thecomposition at a level less than 1 wt %, such as less than 0.7 wt %,less than 0.5 wt %, or less than 0.4 wt %, based on weight of thecomposition. In some cases, the N-oxide of the active pharmaceuticalagent is present in the composition at a level ranging from 0.01 wt % to1 wt %, such as from 0.05 wt % to 0.4 wt %, 0.1 wt % to 0.4 wt %, orfrom 0.1 wt % to 0.2 wt %, based on weight of the composition.

In some aspects, the present disclosure relates to sustained releasedrug delivery formulations having low amounts of bupivacaine N-oxide(Formula II):

In some cases, the bupivacaine N-oxide is present in the composition ata level less than 1 wt %, such as less than 0.7 wt %, or less than 0.4wt %, based on weight of the composition. In some cases, the bupivacaineN-oxide is present in the composition at a level ranging from 0.01 wt %to 1 wt %, such as from 0.05 wt % to 0.4 wt %, or from 0.1 wt % to 0.2wt %, based on weight of the composition.

In some cases, compositions are made from ingredients having low levelsof peroxide. For instance, the compositions may be made by combining: anactive pharmaceutical agent; a high viscosity liquid carrier material(HVLCM) comprising sucrose acetate isobutyrate having peroxide that ispresent at a level less than 200 ppm; and an organic solvent. In somecases, the sucrose acetate isobutyrate has peroxide that is present at alevel less than 100 ppm, such as less than 80 ppm or less than 60 ppm.In some cases, the sucrose acetate isobutyrate has peroxide that ispresent at a level ranging from 1 ppm to 100 ppm, such as from 2 ppm to80 ppm or from 3 ppm to 60 ppm.

In some cases, the compositions may be made by combining: an activepharmaceutical agent; at least one of a high viscosity liquid carriermaterial (HVLCM) and a polyorthoester; and an organic solvent havingperoxide that is present at a level less than 100 ppm, the organicsolvent optionally comprising at least one of benzyl alcohol, dimethylsulfoxide, and triacetin. In some cases, the organic solvent hasperoxide that is present at a level less than 85 ppm, such as less than10 ppm. In some cases, the organic solvent has peroxide that is presentat a level ranging from 1 ppm to 90 ppm, such as from 2 ppm to 85 ppm orfrom 3 ppm to 10 ppm.

In some cases, the amount of degradation products (e.g.,2,6-dimethylaniline, bupivacaine N-oxide) in the subject compositionsmay be measured by IPLC with UV detection. In other cases, the amount of2,6-dimethylaniline is determined by nuclear magnetic resonance (NMR)spectroscopy. In some cases, the amount of 2,6-dimethylaniline isdetermined by gas chromatography (e.g., gas chromatography-massspectrometry, GCMS). In some cases, the amount of 2,6-dimethylaniline isdetermined by liquid chromatography (e.g., liquid chromatography-massspectrometry, LCMS). Unless specified otherwise, the amount of2,6-dimethylaniline recited in the claims is determined by LCMS. In somecases, the amount of 2,6-dimethylaniline may be measured byelectrochemical detection as described in FIJALEK et al., Journal ofPharmaceutical and Biomedical Analysis, 37:913-918 (2005), which isincorporated herein by reference in its entirety.

In some cases, the amount of peroxide is measured by potentiometrictitration, e.g., iodometric titration. Other techniques for measuringthe amount of peroxide include voltamperometric method,spectrophotometry (e.g., using cobalt bicarbonate with light absorbancemeasured at 400 nm, titanium oxalate with light absorbance measured at260 nm, or peroxidase enzyme with light absorbance measured at 596 nm),fluorometry, fluorescence correlation spectroscopy (FCS),chemiluminescence, electrochemistry, ion chromatography (IC), andresonance light scattering (RLS). Unless specified otherwise, the amountof peroxide recited in the claims is determined by spectrophotometryusing cobalt bicarbonate with light absorbance measured at 400 nm.

In one aspect, the present disclosure relates to sterilization ofsustained release drug delivery formulations without the formation ofunacceptable levels of degradation products including genotoxicimpurities.

It was discovered that, in some cases, gamma irradiation is not anacceptable sterilization method because gamma irradiation significantlyincreased levels of degradation products, including a known genotoxicdegradant, 2,6-dimethylaniline.

An evaluation of alternate sterilization techniques was conducted usingan exemplary formulation consisting of 12 wt % bupivacaine, 66 wt %sucrose acetate isobutyrate (SAIB), and 22 wt % benzyl alcohol(“Formulation A”). The sterilization techniques included: dry heatsterilization, steam sterilization, and filtration sterilizationfollowed by aseptic processing. The evaluation concluded that:

-   -   In some cases, the use of dry heat to sterilize was not        acceptable because dry heat sterilization temperatures were        above the flash point of the product and required that the        product be exposed to elevated temperatures for extended periods        of time. The flash point of Formulation A is 116° C. (closed        cup); a typical sterilization cycle is 170° C. for not less than        2 hours. Although precautions may be taken to heat product to        this temperature, the safety of the personnel and plant did not        justify the risk. In addition, in some cases,        fluorocarbon-coated stoppers cannot withstand typical dry heat        sterilization (e.g., 250° C. for ≥30 minutes).    -   The use of steam to sterilize Formulation A was not acceptable        because the formulation is non-aqueous. Steam sterilization uses        saturated steam at high pressure to denature cells. Aqueous        products in vials use the water in the formulation to create        this steam and pressure within the headspace of the container,        sterilizing the contents. Additionally, steam sterilization        temperatures are above the flash point of the product, creating        the same safety issue as described for dry heat sterilization.    -   The use of filtration sterilization followed by aseptic        processing for Formulation A is acceptable because it provides        the product with a sterility assurance level of greater than        10⁻³ without compromising the product. In addition, the inherent        anti-microbial activity of the Formulation A ensures that        pre-filtration bioburden will be consistently low, thereby,        ensuring a safe filter sterilization outcome.

Therefore, the optimal sterilization method for manufacturing theexemplary formulation is filtration sterilization followed by asepticprocessing. As used herein, “aseptic processing” means processing understerile conditions. Aseptic processing eliminates the risk of productdegradation and toxicity that would arise if the product was subjectedto ionizing radiation at doses sufficient to comply with current ISOrequirements (e.g., 20 kGy to 25 kGy of gamma irradiation).

In addition to finalizing aseptic processing as the choice ofsterilization techniques, a processing study was conducted thatidentified the optimal compounding and filling temperatures to minimizethe formation of 2,6-dimethylaniline during manufacture.

In some cases, methods of the present disclosure include processing thesubject compositions. Methods of processing the subject compositionsaccording to certain cases, include filtering a composition having oneor more active agents (e.g., anesthetic, NSAID, etc. as described below)and aseptically processing the composition. In some cases, thecomposition (as described in greater detail below) may be filtered usinga filter having pore sizes which vary, ranging from 0.1 nm to 1000 nm,such as from 0.5 nm to 950 nm, such as from 1 nm to 900 nm, such as from10 nm to 800 nm, such as from 25 nm to 750 nm, such as from 50 nm to 500nm and including filtering with a filter having pore sizes of from 100nm to 400 nm. The composition may be filtered under positive, negativeor atmospheric pressure. The composition may be filtered while heatingthe composition. In some instances, the composition is heated by 1° C.or more during filtration, such as by 2° C. or more, such as 3° C. ormore, such as by 4° C. or more, such as by 5° C. or more, such as by 10°C. or more, such as by 15° C. or more, such as by 20° C. or more andincluding by 25° C. or more. In some cases, the composition is heated toa temperature of from 10° C. to 75° C. during filtration, such as from15° C. to 70° C., such as from 20° C. to 65° C., such as from 25° C. to60° C., such as from 30° C. to 55° C. and including from 40° C. to 50°C.

In some cases, aseptic processing of the composition includes fillingthe composition into a container under a gaseous atmosphere. In someinstances, the gaseous atmosphere includes an inert gas. Inert gases ofinterest may include, but are not limited to, nitrogen, helium, neon,argon, krypton, xenon, and carbon dioxide or a combination thereof. Insome cases, the amount of gas is sufficient to fill the headspace of thecontainer. The term “headspace” is used herein in its conventional senseto refer to the volume in the container between the interface of thecomposition and the opening of the container or at the interface of theclosure (e.g., when the container is sealed with a stopper). The gaspressure of the inert gas atmosphere in the headspace of the containermay be 0.001 torr or more, such as 0.005 torr or more, such as 0.01 torror more, such as 0.05 torr or more, such as 0.1 torr or more, such as0.5 torr or more, such as 1 torr or more, such as 5 torr or more, suchas 10 torr or more, such as 25 torr or more, such as 50 torr or more,such as 100 torr or more, such as 250 torr or more, such as 500 torr ormore, such as 760 torr or more and including 1000 torr or more.

In some instances, aseptic processing of the composition includesclosing the container with a closure. In some cases, the closure isformed from (or coated with) a compound that is inert to the componentsof the subject compositions (as described in greater detail below). Insome cases, the closure forms a fluidic seal with the container. In somecases, the closure forms a fluidic and gaseous seal with the container.

It was discovered that, in some cases, exposure to light (e.g.,simulated sunlight, sunlight, UV light, and visible light) can result information of degradation products in sustained release drug deliveryformulations.

It was also discovered that, in some cases, storage of sustained releasedrug delivery formulations in amber colored glassware causes the levelsof 2,6-dimethylaniline to be high.

In some cases, the light induced degradation is prevented by storing theproduct in appropriate light resistant cartons.

In some cases, the drug delivery formulation is stored in a lightresistant container. In some cases, the light resistant containercomprises a protective light resistant coating, e.g., RAY-SORB® coating.In some cases, the subject light resistant containers are configured toreduce or eliminate light-induced degradation by preventing exposure ofthe subject compositions to light having a wavelength that ranges from200 nm to 800 nm, such as from 225 nm to 775 nm, such as from 250 nm to750 nm, such as from 275 nm to 725 nm, such as from 300 nm to 700 nm,such as from 325 nm to 675 nm, such as from 350 nm to 650 nm, such asfrom 375 nm to 625 nm and including from 400 nm to 600 nm. In certaincases, the light resistant containers have an optical density at thewavelength where a reduction in light exposure is desired of 0.5 ormore, such as 1 or more, such as 1.5 or more, such as 2.0 or more, suchas 2.5 or more, such as 3.0 or more, such as 3.5 or more, such as 4.0 ormore, such as 4.5 or more, such as 5.0 or more, such as 5.5 or more,such as 6.0 or more, such as 6.5 or more and including an opticaldensity of 7.0 or more. In certain instances, the light resistantcontainer is completely opaque to the wavelength of light wherereduction of light exposure is desired (i.e., no light passes throughthe walls of the container).

It was discovered that, in some cases, siliconized stoppers leachsilicone oil into sustained release drug delivery formulations. In somecases, dose units of the subject compositions are stored (e.g., loaded,dispensed from) in a container having a closure (e.g., a stopper, lid orcap) that is substantially inert to components of the composition, suchas to the organic solvent present in the composition (e.g., benzylalcohol). As used herein, “substantially inert” means that the subjectcomposition does not leach from or react with the closure (i.e., contactbetween the composition and the closure does not result in the formationor presence of degradation or undesired byproducts in the composition).In some cases, the closure exhibits no reactivity with the compositioneven when in contact for 1 hour or longer, such as for 2 hours orlonger, such as for 6 hours or longer, such as for 12 hours or longer,such as for 24 hours or longer, such as for 1 week or longer, such asfor 1 month or longer, such as for 6 months or longer, such as for 1year or longer and including for 10 years or longer. In some instances,closures of interest include fluorinated polymer. In some cases, theclosure is formed from the fluorinated polymer. In some cases, theclosure is coated with the fluorinated polymer. Fluorinated polymers ofinterest may include but are not limited to fluoropolymers formed fromone or more monomers selected from the groupethylene-tetrafluoroethylene, perfluorocycloalkene (PFCA), vinylfluoride (fluoroethylene, VF1), vinylidene fluoride(1,1-difluoroethylene, VDF, VF2), tetrafluoroethylene (TFE),chlorotrifluoroethylene (CTFE), hexafluoropropylene (HFP),perfluoropropylvinylether (PPVE), perfluoromethylvinylether (PMVE). Forinstance, the closure may be formed from polyvinylfluoride (PVF),polyvinylidene fluoride (PVDF), polytetrafluoroethylene (PTFE),polychlorotrifluoroethylene (PCTFE), perfluoroalkoxypolymer (PFA),fluorinated ethylene-propylene (FEP), polyethylenetetrafluoroethylene(ETFE), polyethylenechlorotrifluoroethylene (ECTFE), perfluorinatedelastomer (FFPM/FFKM), fluorocarbon chlorotrifluoroethylenevinylidenefluoride (FPM), fluoroelastomer tetrafluoroethylene-propylene (FEPM),perfluoropolyether (PFPE) or perfluorosulfonic acid (PFSA). In certaincases, the closure does not include silicon.

In some cases, the stopper is paired with a glass container (e.g., glassvial), e.g., a 10 mL USP Type I Glass Vial. In some cases, the glassvial is pyrex glass, a boron silica glass or other type of glass. Incertain instances, the glass vial is formed from a glass material whichdoes not contain iron.

In some cases, the presence of organic solvent, e.g., 22 wt % benzylalcohol, necessitated the selection of a stopper that was chemicallyresistant to organic solvents.

In some cases, the present disclosure provides dosage systems that arefree of silicone oil.

In some cases, the present disclosure provides a fluorocarbon-coatedstopper that can release fluoride ions when exposed to gammairradiation. As a result, in some cases, the dosage system is notexposed to gamma irradiation.

In some cases, the present disclosure involves control of metal contentin sustained release drug delivery formulations.

The manufacturing of sustained release drug delivery formulations, fromthe source of raw materials to the compounding, filling, and storage incontainers (e.g., glass vials with stoppers), may be conducted in a wayto minimize metals in the final product. In some cases, the metalcontent is minimized by using steel compounding tanks. In some cases,the metal content is minimized by using silicone tubing. In some cases,the metal content is minimized by using fluorocarbon-coated stoppers.

In some cases, a composition comprises metal present at a level lessthan 5 ppm, such as less than 4 ppm, or less than 3 ppm. In some cases,the composition comprises metal present at a level ranging from 0.1 ppmto 4 ppm, such as from 0.05 ppm to 3 ppm or from 0.1 ppm to 2 ppm. Askilled artisan would understand that the metal content includes metalin any form, including metal in elemental or ionized form.

In some cases, the present disclosure relates to a composition havinglow water content. For instance, the water may be present at a levelless than 0.5 wt %, such as less than 0.4 wt %, based on weight of thecomposition, or less than 0.3 wt %, based on weight of the composition.The water may be present in the composition at a level ranging from 0.03wt % to 0.4 wt %, such as from 0.05 wt % to 0.35 wt %, from 0.08 wt % to0.3 wt %, based on weight of the composition.

While not wishing to be bound by theory, in some cases, the watercontent is believed to affect the amount of hydrolysis that occurs inthe compositions. In some cases, sucrose acetate isobutyrate and benzylalcohol undergo a hydrolysis reaction to form benzyl acetate and/orbenzyl isobutyrate. It is believed that keeping the water content lowreduces the amount of benzyl acetate and benzyl isobutyrate formation.The water content may be kept low by several techniques, such as usingingredients with low water content, storing ingredients in closedcontainers, and using a nitrogen head space while compounding.

In view of the above, in some cases, the present disclosure involvescompositions having low benzyl acetate content. For instance, the benzylacetate may be present at a level less than 100 mg/mL, such as less than90 mg/mL, less than 80 mg/mL, less than 70 mg/mL, less than 60 mg/mL,less than 50 mg/mL, less than 40 mg/mL, less than 30 mg/mL, less than 20mg/mL, less than 15 mg/mL, or less than 10 mg/mL. The benzyl acetate maybe present in the composition at a level ranging from 0.1 mg/mL to 80mg/mL, such as from 0.5 mg/mL to 40 mg/mL, from 1 mg/mL to 20 mg/mL, or1 mg/mL to 15 mg/mL. In some cases, the benzyl acetate is present in thecomposition in an amount of 1 mg/mL, 2 mg/mL, 3 mg/mL, 4 mg/mL, 5 mg/mL,6 mg/mL, 7 mg/mL, 8 mg/mL, 9 mg/mL, 10 mg/mL, 11 mg/mL, 12 mg/mL, 13mg/mL, 14 mg/mL, 15 mg/mL, 16 mg/mL, 17 mg/mL, 18 mg/mL, 19 mg/mL, 20mg/mL, 21 mg/mL, 22 mg/mL, 23 mg/mL, 24 mg/mL, 25 mg/mL, 26 mg/mL, 27mg/mL, 28 mg/mL, 29 mg/mL, 30 mg/mL, 31 mg/mL, 32 mg/mL, 33 mg/mL, 34mg/mL, 35 mg/mL, 36 mg/mL, 37 mg/mL, 38 mg/mL, 39 mg/mL, 40 mg/mL, 41mg/mL, 42 mg/mL, 43 mg/mL, 44 mg/mL, 45 mg/mL, 46 mg/mL, 47 mg/mL, 48mg/mL, 49 mg/mL, 50 mg/mL, 51 mg/mL, 52 mg/mL, 53 mg/mL, 54 mg/mL, 55mg/mL, 56 mg/mL, 57 mg/mL, 58 mg/mL, 59 mg/mL, 60 mg/mL, 61 mg/mL, 62mg/mL, 63 mg/mL, 64 mg/mL, 65 mg/mL, 66 mg/mL, 67 mg/mL, 68 mg/mL, 69mg/mL, 70 mg/mL, 71 mg/mL, 72 mg/mL, 73 mg/mL, 74 mg/mL, 75 mg/mL, 76mg/mL, 77 mg/mL, 78 mg/mL, 79 mg/mL, 80 mg/mL, 81 mg/mL, 82 mg/mL, 83mg/mL, 84 mg/mL, 85 mg/mL, 86 mg/mL, 87 mg/mL, 88 mg/mL, 89 mg/mL, 90mg/mL, 91 mg/mL, 92 mg/mL, 93 mg/mL, 94 mg/mL, 95 mg/mL, 96 mg/mL, 97mg/mL, 98 mg/mL, 99 mg/mL or 100 mg/mL.

In some cases, the present disclosure involves compositions having lowbenzyl isobutyrate content. For instance, the benzyl isobutyrate may bepresent at a level less than 50 mg/mL, such as less than 40 mg/mL, lessthan 30 mg/mL, less than 20 mg/mL, less than 30 mg/mL, less than 10mg/mL, or less than 8 mg/mL. The benzyl isobutyrate may be present inthe composition at a level ranging from 0.1 mg/mL to 40 mg/mL, such asfrom 0.5 mg/mL to 30 mg/mL, from 1 mg/mL to 10 mg/mL, or 1 mg/mL to 8mg/mL. In some cases, the benzyl isobutyrate is present in thecomposition in an amount of 1 mg/mL, 2 mg/mL, 3 mg/mL, 4 mg/mL, 5 mg/mL,6 mg/mL, 7 mg/mL, 8 mg/mL, 9 mg/mL, 10 mg/mL, 11 mg/mL, 12 mg/mL, 13mg/mL, 14 mg/mL, 15 mg/mL, 16 mg/mL, 17 mg/mL, 18 mg/mL, 19 mg/mL, 20mg/mL, 21 mg/mL, 22 mg/mL, 23 mg/mL, 24 mg/mL, 25 mg/mL, 26 mg/mL, 27mg/mL, 28 mg/mL, 29 mg/mL, 30 mg/mL, 31 mg/mL, 32 mg/mL, 33 mg/mL, 34mg/mL, 35 mg/mL, 36 mg/mL, 37 mg/mL, 38 mg/mL, 39 mg/mL, 40 mg/mL, 41mg/mL, 42 mg/mL, 43 mg/mL, 44 mg/mL, 45 mg/mL, 46 mg/mL, 47 mg/mL, 48mg/mL, 49 mg/mL or 50 mg/mL.

While not wishing to be bound by theory, in some cases, it is believedthat the amount of peroxide in the composition may affect the amount ofN-oxide formation. Reducing the amount of peroxide is believed to reducethe amount of N-oxide formation. The amount of peroxide in thecomposition may be kept low by several techniques, such as usingingredients that have low peroxide content, protecting the compositionfrom light, minimizing the headspace in the container containing thecomposition, and storing the composition at low temperature, such asroom temperature.

In some cases, the present the composition is made with HVLCM (e.g.,sucrose acetate isobutyrate) having low peroxide content. For instance,the HVLCM may have peroxide present at a level less than 200 ppm, suchless than 100 ppm, less than 80 ppm, or less than 60 ppm. In some cases,the HVLCM has peroxide that is present at a level ranging from 1 ppm to100 ppm, such as from 2 ppm to 80 ppm or from 3 ppm to 60 ppm.

In some cases, the present the composition is made with organic solvent(e.g., benzyl alcohol) having low peroxide content. For instance, theorganic solvent may have peroxide that is present at a level less than100 ppm, such as less than 85 ppm or less than 10 ppm. In some cases,the organic solvent has peroxide that is present at a level ranging from1 ppm to 90 ppm, such as from 2 ppm to 85 ppm or from 3 ppm to 10 ppm.

In some aspects, the present disclosure relates to active agentcompositions (e.g., bupivacaine compositions) having little to noparticulate matter. In some cases, particulate matter is present in thecompositions at a level less than 100 ppm, less than 95 ppm, less than90 ppm, less than 85 ppm, less than 80 ppm, less than 75 ppm, less than70 ppm, less than 65 ppm, less than 60 ppm, less than 55 ppm andincluding less than 50 ppm. For example, particulate matter may bepresent in the compositions at a level of 1 ppm, 2 ppm, 3 ppm, 4 ppm, 5ppm, 6 ppm, 7 ppm, 8 ppm, 9 ppm, 10 ppm, 11 ppm, 12 ppm, 13 ppm, 14 ppm,15 ppm, 16 ppm, 17 ppm, 18 ppm, 19 ppm, 20 ppm, 21 ppm, 22 ppm, 23 ppm,24 ppm, 25 ppm, 26 ppm, 27 ppm, 28 ppm, 29 ppm, 30 ppm, 31 ppm, 32 ppm,33 ppm, 34 ppm, 35 ppm, 36 ppm, 37 ppm, 38 ppm, 39 ppm, 40 ppm, 41 ppm,42 ppm, 43 ppm, 44 ppm, 45 ppm, 46 ppm, 47 ppm, 48 ppm, 49 ppm, 50 ppm,51 ppm, 52 ppm, 53 ppm, 54 ppm, 55 ppm, 56 ppm, 57 ppm, 58 ppm, 59 ppm,60 ppm, 61 ppm, 62 ppm, 63 ppm, 64 ppm, 65 ppm, 66 ppm, 67 ppm, 68 ppm,69 ppm, 70 ppm, 71 ppm, 72 ppm, 73 ppm, 74 ppm, 75 ppm, 76 ppm, 77 ppm,78 ppm, 79 ppm, 80 ppm, 81 ppm, 82 ppm, 83 ppm, 84 ppm, 85 ppm, 86 ppm,87 ppm, 88 ppm, 89 ppm, 90 ppm, 91 ppm, 92 ppm, 93 ppm, 94 ppm, 95 ppm,96 ppm, 97 ppm, 98 ppm, 99 ppm, 100 ppm. In certain cases, thecomposition has no particulate matter, i.e., 0 ppm particulate matter.

The stability of the formulations also depends on storage conditions.High temperature storage typically increases degradation. In some cases,low temperature storage can cause precipitation. Thus, the compositionsof the present disclosure are typically stored at a temperature rangingfrom 15° C. to 30° C., such as from 20° C. to 25° C.

In some cases, when a composition is stored in a sealed, upright, clearglass vial at 25° C./60% RH for 20 months or 36 months,2,6-dimethylaniline is present at levels disclosed herein, e.g., whenthe composition is stored in a sealed, upright, clear glass vial at 25°C./60% RH for 20 months or 36 months, the 2,6-dimethylaniline may bepresent at a level less than 500 ppm. In some cases, when a compositionis stored in a sealed, upright, clear glass vial at 25° C./60% RH for 20months or 36 months, the 2,6-dimethylaniline is present at a level lessthan 100 times, such as less than 50 times, less than 20 times, lessthan 10 times, less than 8 times, less than 6 times, less than 4 times,or less than 2 times, relative to an initial level before storage, suchas ranging from 1 time to 20 times, such as 2 times to 10 times, or 2times to 4 times, relative to an initial level before storage.

In some cases, when a composition is stored in a sealed, upright, clearglass vial at 40° C./75% RH for 20 months or 36 months,2,6-dimethylaniline is present at levels disclosed herein. In somecases, when a composition is stored in a sealed, upright, clear glassvial at 40° C./75% RH for 20 months or 36 months, the2,6-dimethylaniline is present at a level less than 100 times, such asless than 50 times, less than 20 times, less than 10 times, less than 8times, less than 6 times, less than 4 times, or less than 2 times,relative to an initial level before storage such as ranging from 1 timeto 20 times, such as 2 times to 10 times, or 2 times to 4 times,relative to an initial level before storage.

In some cases, when a composition is stored in a sealed, upright, clearglass vial at 25° C./60% RH for 20 months or 36 months, N-oxide of theactive pharmaceutical agent is present at levels disclosed herein, e.g.,at a level less than 1 wt %, based on weight of the composition. In somecases, when a composition is stored in a sealed, upright, clear glassvial at 25° C./60% RH for 20 months or 36 months, the N-oxide of theactive pharmaceutical agent is present at a level less than 10 times,such as less than 5 times, less than 2 times, or less than 1.5 timesrelative to an initial level before storage, such as ranging from 1 timeto 5 times or 1 time to 2 times, relative to an initial level beforestorage.

In some cases, when a composition is stored in a sealed, upright, clearglass vial at 40° C./75% RH for 20 months or 36 months, N-oxide of theactive pharmaceutical agent is present at levels disclosed herein, e.g.,at a level less than 1 wt %, based on weight of the composition. In somecases, when a composition is stored in a sealed, upright, clear glassvial at 40° C./75% RH for 20 months or 36 months, the N-oxide of theactive pharmaceutical agent is present at a level less than 10 times,such as less than 5 times, less than 2 times, or less than 1.5 times,relative to an initial level before storage, such as ranging from 1 timeto 5 times or 1 time to 2 times, relative to an initial level beforestorage.

In some cases, when a composition is stored in a sealed, upright, clearglass vial at 25° C./60% RH for 20 months or 36 months, metal is presentat levels disclosed herein, e.g., at a level less than 5 ppm. In somecases, when a composition is stored in a sealed, upright, clear glassvial at 40° C./75% RH for 20 months or 36 months, the metal is presentat levels disclosed herein.

In some cases, when a composition is stored in a sealed, upright, clearglass vial at 25° C./60% RH for 20 months or 36 months, water is presentat levels disclosed herein, e.g., at a level less than 0.5 wt %, basedon weight of the composition. In some cases, when a composition isstored in a sealed, upright, clear glass vial at 40° C./75% RH for 20months or 36 months, the water is present at levels disclosed herein.

In some cases, when a composition is stored in a sealed, upright, clearglass vial at 25° C./60% RH for 20 months or 36 months, benzyl acetateis present at levels disclosed herein, e.g., at a level less than 100mg/mL. In some cases, when a composition is stored in a sealed, upright,clear glass vial at 25° C./60% RH for 20 months or 36 months, the benzylacetate is present at a level less than 20 times or less than 15 times,relative to an initial level before storage, such as ranging from 1 timeto 20 times or 2 times to 15 times, relative to an initial level beforestorage.

In some cases, when a composition is stored in a sealed, upright, clearglass vial at 40° C./75% RH for 20 months or 36 months, benzyl acetateis present at levels disclosed herein, e.g., at a level less than 100mg/mL. In some cases, when a composition is stored in a sealed, upright,clear glass vial at 40° C./75% RH for 20 months or 36 months, the benzylacetate is present at a level less than 20 times or less than 15 times,relative to an initial level before storage, such as ranging from 1 timeto 20 times or 2 times to 15 times, relative to an initial level beforestorage.

In some cases, when a composition is stored in a sealed, upright, clearglass vial at 25° C./60% RH for 20 months or 36 months, benzylisobutyrate is present at levels disclosed herein, e.g., at a level lessthan 50 mg/mL. In some cases, when a composition is stored in a sealed,upright, clear glass vial at 25° C./60% RH for 20 months or 36 months,the benzyl isobutyrate is present at a level less than 20 times, such asless than 10 times, or less than 8 times, relative to an initial levelbefore storage, such as ranging from 1 time to 10 times or 2 times to 8times, relative to an initial level before storage.

In some cases, when a composition is stored in a sealed, upright, clearglass vial at 40° C./75% RH for 20 months, benzyl isobutyrate is presentat levels disclosed herein, e.g., at a level less than 50 mg/mL. In somecases, when a composition is stored in a sealed, upright, clear glassvial at 40° C./75% RH for 20 months, the benzyl isobutyrate is presentat a level less than 20 times, such as less than 10 times, or less than8 times, relative to an initial level before storage, such as rangingfrom 1 time to 10 times or 2 times to 8 times, relative to an initiallevel before storage.

In some cases, when a composition is stored in a sealed, upright, clearglass vial at 25° C./60% RH for 20 months or 36 months, sucrose acetateisobutyrate is present at levels disclosed herein, e.g., at a levelranging from 30 wt % to 80 wt %, based on weight of the composition. Insome cases, when a composition is stored in a sealed, upright, clearglass vial at 40° C./75% RH for 20 months, the sucrose acetateisobutyrate is present at levels disclosed herein, e.g., at a levelranging from 30 wt % to 80 wt %, based on weight of the composition.

Suitable pharmaceutical agents include locally or systemically actingpharmaceutically active agents which may be administered to a subject bytopical or intralesional application (including, for example, applyingto abraded skin, lacerations, puncture wounds, etc., as well as intosurgical wounds or incisions) or by injection, such as subcutaneous,intradermal, intramuscular, intraocular or intra-articular injection.Suitable pharmaceutical agents include polysaccharides, DNA and otherpolynucleotides, antisense oligonucleotides, antigens, antibodies,vaccines, vitamins, enzymes, proteins, naturally occurring orbioengineered substances, and the like, anti-infectives (includingantibiotics, antivirals, fungicides, scabicides or pediculicides),antiseptics (e.g., benzalkonium chloride, benzethonium chloride,chlorhexidine gluconate, mafenide acetate, methylbenzethonium chloride,nitrofurazone, nitromersol and the like), steroids (e.g., estrogens,progestins, androgens, adrenocorticoids and the like), opioids (e.g.,buprenorphine, butorphanol, dezocine, meptazinol, nalbuphine,oxymorphone and pentazocine), therapeutic polypeptides (e.g., insulin,erythropoietin, morphogenic proteins such as bone morphogenic protein,and the like), analgesics and anti-inflammatory agents (e.g., aspirin,ibuprofen, naproxen, ketorolac, COX-1 inhibitors, COX-2 inhibitors andthe like), antipsychotic agents (for example, phenothiazines includingchlorpromazine, triflupromazine, mesoridazine, piperacetazine andthioridazine; thioxanthenes including chlorprothixene and the like),antiangiogenic agents (e.g., combresiatin, contortrostatin, anti-VEGFand the like), anti-anxiety agents (for example, benzodiazepinesincluding diazepam, alprazolam, clonazepam, oxazepam; and barbiturates),antidepressants (including tricyclic antidepressants and monoamineoxidase inhibitors including imipramine, amitriptyline, doxepin,nortriptyline, amoxapine, tranylcypromine, phenelzine and the like),stimulants (for example, methylphenidate, doxapram, nikethamide and thelike), narcotics (for example, buprenorphine, morphine, meperidine,codeine and the like), analgesic-antipyretics and anti-inflammatoryagents (for example, aspirin, ibuprofen, naproxen and the like), localanesthetics (e.g., the amide- or anilide-type local anesthetics such asbupivacaine, levobupivacaine, dibucaine, mepivacaine, procaine,lidocaine, tetracaine, ropivacaine, and the like), fertility controlagents, chemotherapeutic and anti-neoplastic agents (for example,mechlorethamine, cyclophosphamide, 5-fluorouracil, thioguanine,carmustine, lomustine, melphalan, chlorambucil, streptozocin,methotrexate, vincristine, bleomycin, vinblastine, vindesine,dactinomycin, daunorubicin, doxorubicin, tamoxifen and the like),cardiovascular and anti-hypertensive agents (for example, procainamide,amyl nitrite, nitroglycerin, propranolol, metoprolol, prazosin,phentolamine, trimethaphan, captopril, enalapril and the like), drugsfor the therapy of pulmonary disorders, anti-epilepsy agents (forexample, phenyloin, ethotoin and the like), anti-hidrotics,keratoplastic agents, pigmentation agents or emollients, antiemeticagents (such as ondansetron, granisetron, tropisetron, metoclopramide,domperidone, scopolamine, palonosetron, and the like). The compositionof the present application may also be applied to other locally actingactive agents, such as astringents, antiperspirants, irritants,rubefacients, vesicants, sclerosing agents, caustics, escharotics,keratolytic agents, sunscreens and a variety of dermatologics includinghypopigmenting and antipruritic agents.

In some cases, the active pharmaceutical agent is present in an amountranging from 0.5 to 20 percent, 1 to 8 percent, 2 to 6 percent, 2 to 5percent, or 1 to 5 percent by weight of the composition. In some cases,the active pharmaceutical agent is present in the composition in anamount ranging from 1 wt % to 25 wt %, such as from 5 wt % to 20 wt %,from 10 wt % to 15 wt %, or about 12 wt %, based on weight of thecomposition.

In some cases, the compositions include an amide- or anilide-type localanesthetic of the “caine” classification, and a non-steroidalanti-inflammatory drug (NSAID), along with related methods, e.g., fortreatment of post-operative pain or for prophylactic treatment of pain.

As used herein, the term “anesthetic” intends any agent that providesreversible local numbness, pain relief, blocks impulse conduction alongnerve axions and other excitable membranes, such as a regional blockageof nociceptive pathways (afferent and/or efferent), analgesia, and/oranesthesia. See, e.g., Strichartz, G. R. (Ed.) Local Anesthetics,Handbook of Experimental Pharmacology, vol. 81, Springer, Berlin/NewYork, (1987). The term also includes any agent which, when locallyadministered provides localized (regional) full or partial inhibition ofsensory perception and/or motor function. Examples of commonly usedagents suitable for use as anesthetics include, but are not limited toambucaine, amolanone, amylcaine, benoxinate, benzyl alcohol, benzocaine,betoxycaine, biphenamine, bupivacaine, butacaine, butamben,butanilicaine, butethamine, butoxycaine, carticaine, chloroprocaine,cocaethylene, cocaine, cyclomethycaine, dibucaine, dimethisoquin,dimethocaine, diperodon, dyclonine, ecogonidine, ecogonine, etidocaine,euprocin, fenalcomine, formocaine, hexylcaine, hydroxyteteracaine,isobuanine, isobutyl p-aminobenzoate, leucinocaine, levobupivacaine,levoxadrol, lidocaine, mepivacaine, meprylcaine, metabutoxycaine, methylchloride, myrtecaine, naepaine, octacaine, orthocaine, oxethazaine,parenthoxycaine, phenacaine, phenol, piperocaine, piridocaine,polidocanol, pramoxine, prilocaine, procaine, propanocaine,proparacaine, propipocaine, propoxycaine, pseudococaine, pyrrocaine,ropivacaine, salicyl alcohol, tetracaine, tolycaine, trimecaine,xylocaine, zolamine, anesthetically active derivatives, analogs and anypharmaceutically acceptable salt thereof, and any mixture thereof.

The amide- and ester-type of local anesthetics are preferred for useherein. Amide-type local anesthetics are characterized by having anamide functionality, while ester-type local anesthetics contain an esterfunctionality. Preferred amide-type local anesthetics include lidocaine,bupivacaine, prilocaine, mepivacaine, etidocaine, ropivacaine anddibucaine. Preferred ester-type local anesthetics include tetracaine,procaine, benzocaine and chloroprocaine. In one case, the amide-typelocal anesthetic is selected from the group consisting of bupivacaine,ropivacaine, levobupivacaine, dibucaine, mepivacaine, procaine,lidocaine, and tetracaine. The most preferred local anesthetic isbupivacaine.

In some cases, degradation of the active pharmaceutical agent may resultin formation of 2,6-dimethylaniline. For instance, the activepharmaceutical agent may be at least one member selected frombupivacaine, lidocaine, ropivicaine, etidocaine, mepivacaine,pyrrocaine, or salts thereof.

The anesthetic agent is provided in the composition in a neutral form,as a free base form, or in the form of a pharmaceutically acceptablesalt. The term “pharmaceutically acceptable salt,” as used herein,intends those salts that retain the biological effectiveness andproperties of neutral anesthetics and are not otherwise unacceptable forpharmaceutical use. Pharmaceutically acceptable salts include salts ofacidic or basic groups, which groups may be present in the anestheticagents. Those anesthetic agents that are basic in nature are capable offorming a wide variety of salts with various inorganic and organicacids. Pharmaceutically acceptable acid addition salts of basicanesthetics suitable for use herein are those that form non-toxic acidaddition salts, i.e., salts comprising pharmacologically acceptableanions, such as the hydrochloride, hydrobromide, hydroiodide, nitrate,sulfate, bisulfate, phosphate, acid phosphate, isonicotinate, acetate,lactate, salicylate, citrate, tartrate, pantothenate, bitartrate,ascorbate, succinate, maleate, gentisinate, fumarate, gluconate,glucaronate, saccharate, formate, benzoate, glutamate, methanesulfonate,ethanesulfonate, benzenesulfonate, p-toluenesulfonate and pamoate (i.e.,1,1′-methylene-bis-(2-hydroxy-3-naphthoate)) salts. Anesthetic agentsthat include an amino moiety may form pharmaceutically acceptable saltswith various amino acids, in addition to the acids mentioned above.Suitable base salts can be formed from bases which form non-toxic salts,for example, aluminium, calcium, lithium, magnesium, potassium, sodium,zinc and diethanolamine salts. See, e.g., Berge et al. (1977) J. Pharm.Sci. 66:1-19.

The ability of an anesthetic agent to provide a condition of sustainedlocal anesthesia refers to the ability of the subject agent to establishan assessable state of localized (regional) full or partial inhibitionof sensory perception and/or motor function. Numerous methods and toolsfor making such an assessment will readily occur to the skilled artisan.With regard to non-human animal subjects, these methods includemeasurement of spontaneous locomotion in test rats (using, for example,commercially available equipment and software from Med Associates Inc.,St. Albans, Vt.), where data can be collected on total distancetraveled, ambulatory counts, stereotypy, rearing, time spent in thevarious motions and time spent at rest for test subjects; visualizationof pin prick reaction in rats; and the rat hotplate foot withdrawalmodel, e.g., according to the procedure described in detail in IACUC No9511-2199.

With regard to selection of a particular anesthetic agent, the skilledartisan will also recognize that the pharmacological properties of eachcandidate agent will vary, for example, with respect to onset andintensity of anesthetic effect, duration and the like. Certain agentsmay provide a mild anesthetic effect, having a fairly rapid onset ofactivity, but a short duration. Such agents can be used with thecompositions in order to provide an “initial anesthetic effect,” wherethey are typically paired with a different anesthetic agent thatprovides a “sustained local anesthesia,” characterized by a more gradualonset of activity, but a stronger effect and one of longer duration. Anexample of an anesthetic that can be used to provide an initialanesthetic effect is benzyl alcohol. An example of an anesthetic thatcan be used to provide a sustained local anesthesia is bupivacaine.Still further agents that can be used to provide an initial anestheticeffect can include organic materials commonly used as solvents and/orpenetration agents, such as ethanol, dimethyl sulfoxide,N-methylpyrrolidone, polyethylene glycol and certain fatty acid esters.These and other similar agents can provide a very mild initialanesthetic effect, for example, when applied they can cool or otherwisedesensitize/numb a tissue site, thereby partially inhibiting sensoryperception at that site. Whenever an agent is used in order to providean initial anesthetic effect, the agent is provided in a suitablecomposition in an amount sufficient to provide the subject effect, andin such a way that the agent is able to be released from the compositionquickly in order to provide the intended effect. Assembly of suchsuitable compositions (containing an agent for providing an initialanesthetic effect) is within the skill of the art when taken incombination with the guidance and teaching provided by the instantspecification.

In certain cases, a composition is provided that includes two anestheticagents, a first anesthetic and a second anesthetic, wherein the secondanesthetic agent is a solvent for the first anesthetic agent. In theseparticular compositions, the second anesthetic agent is typically usedto provide an initial anesthetic effect, and the first anesthetic agentis used to provide a subsequent anesthetic effect characterized bysustained local anesthesia, having an onset within 2 hours ofadministration to a subject without an initial burst, and a duration ofat least 24 hours after administration, or even longer. In certainpreferred cases, the first anesthetic agent provides the sustained localanesthesia with an onset within 1 to 2 hours of administration, and inother preferred cases, the first anesthetic agent provides the sustainedlocal anesthesia with an onset within 30 minutes to 1 hour ofadministration. In certain other cases, the second anesthetic is also asolvent for the sustained release carrier system.

The concentration of the anesthetic in the composition will also dependon absorption, inactivation, and excretion rates of that particularagent, as well as other factors known to those of skill in the art. Itis to be noted that dosage values will also vary with the severity ofthe condition to be alleviated. It is to be further understood that forany particular subject, specific dosage regimens should be adjusted overtime according to the individual need and the professional judgment ofthe person administering or supervising the administration of thecompositions, and that the concentration ranges set forth herein areexemplary only and are not intended to limit the scope or practice ofthe claimed composition. The composition may be administered in onedosage, or may be divided into a number of smaller doses to beadministered at varying intervals of time, either sequentially orconcurrently.

The anesthetic agent or agents will typically be present in thecomposition in the range from 0.1 to 99.5 percent by weight relative tothe total weight of the composition (wt %), from 0.5 to 70 wt %, or from1 percent to 50 wt %. However, ranges having upper endpoints as low as40%, 30%, 20%, or 10% can be used, as can ranges having lower limits ashigh as 5%, 3%, or 2%. For very active anesthetic agents, the ranges maybe less than 1% by weight, and possibly less than 0.0001%.

An anesthetic agent will serve as a solvent for another anesthetic agentherein when one agent is at least partially dissolved in the othersolvent agent in the manufacture of the composition. In addition, theanesthetic solvent is present in the composition in an amount sufficientto provide both an initial anesthetic effect and at least partiallydissolve the other anesthetic agent. In certain cases, the secondanesthetic is thus present in an amount of from 95 to 1 percent byweight relative to the total weight of the composition (wt %), or in anamount of from 75 to 10 wt %, or in an amount of from 50 to 15 wt %.

A number of suitable anesthetic agents that also serve as solvents forother anesthetic agents can be used. Suitable agents include aromaticalcohols, acids and acid derivatives, and combinations thereof. Aparticularly preferred anesthetic agent that can be used as a solventfor an additional anesthetic is benzyl alcohol.

In some cases, the sustained release carrier systems employed in thecompositions of the present disclosure are classified as non-polymericcarriers. A pharmaceutically acceptable non-polymeric carrier istypically biocompatible, and preferably biodegradable, bioerodible, orbioabsorbable. A substance is biocompatible if it and any of itsdegradation products present no significant, deleterious or untowardeffects, nor cause substantial tissue irritation or necrosis whenadministered to living tissue. “Biodegradable” or “bioerodible,” usedinterchangeably herein, means the subject non-polymeric material willdegrade or erode in vivo to form smaller chemical species, wherein suchdegradation can result, for example, from enzymatic, chemical, andphysical processes. “Bioabsorbable” means that a given nonpolymericmaterial can be broken down and absorbed within an animal subject'sbody, for example, by a cell, tissue or the like.

In some cases, the non-polymeric carrier material is used to controlrelease of at least one anesthetic agent from the compositions, in sucha way as to provide a sustained local anesthesia having an onset within2 hours of administration and a duration of at least 24 hours or longer.In some cases, the non-polymeric carrier material comprises HVLCM (e.g.,sucrose acetate isobutyrate) present in the composition in an amountsufficient to provide sustained release of the active pharmaceuticalagent from the composition, such as sustained release of about 72 hours.In some compositions, the non-polymeric carrier material is sufficientto provide either a first order sustained-release profile of the atleast one anesthetic, or a pseudo-zero order release profile.Accordingly, the non-polymeric carrier will be present in thecomposition in an amount of from 99.5 to 1 percent by weight relative tothe total weight of the composition (wt %), or in an amount of from 95to 10 wt %, or in an amount of from 75 to 25 wt %. In some cases, thenon-polymeric carrier comprises a high viscosity liquid carrier material(HVLCM), e.g., sucrose acetate isobutyrate, present at a level rangingfrom 30 wt % to 80 wt %, such as from 40 wt % to 70 wt %, from 50 wt %to 70 wt %, from 60 wt % to 70 wt %, from 61 wt % to 69 wt %, from 62 wt% to 68 wt %, or from 63 wt % to 67 wt %, based on weight of thecomposition.

Selection of a suitable non-polymeric carrier is within the generalskill in the art, using the teaching and guidance provided by theinstant disclosure and specification. For example, numerouspharmaceutically acceptable non-polymeric carrier systems are availableto the skilled artisan to produce liquid, spray, cream, lotion,ointment, gel, slurry, oil, emulsion, microemulsion, solid, plaster,film, particle, microparticle, powder or other suitable formpharmaceutical compositions. These and other carrier systems aredescribed, for example, in Remington's Pharmaceutical Sciences, 16^(th)Edition, 1980 and 17^(th) Edition, 1985, both published by MackPublishing Company, Easton, Pa.

The compositions may further include one or more additional components,for example pharmaceutically acceptable excipient materials that can actas dispersing agents, bulking agents, binders, carriers, stabilizers,glidants, antioxidants, pH adjusters, anti-irritants, thickening agents,rheology modifiers, emulsifiers, preservatives, and the like. Theskilled artisan will appreciate that certain excipient materials canserve several of the above-referenced functions in any particularformulation. Thus, any number of suitable excipient materials can bemixed with or incorporated into the compositions to provide bulkingproperties, alter active agent release rates, increase or impede wateruptake, control pH, provide structural support, facilitate manufacturingprocesses and other uses known to those skilled in the art. The term“excipient” generally refers to a substantially inert material that isnontoxic and does not interact with other components of the compositionin a deleterious manner. The proportions in which a particular excipientmay be present in the composition depend upon the purpose for which theexcipient is provided and the identity of the excipient.

For example, suitable excipients that can also act as stabilizers foractive agents include pharmaceutical grades of dextrose, sucrose,lactose, trehalose, mannitol, sorbitol, inositol, dextran, and the like.Such stabilizers may thus be a saccharide such as a monosaccharide, adisaccharide, a polysaccharide or a sugar alcohol. Other suitableexcipients include starch, cellulose, sodium or calcium phosphates,calcium sulfate, citric acid, tartaric acid, glycine, and combinationsthereof. Examples of hydrophobic excipients that can be added to slowhydration and dissolution kinetics include fatty acids andpharmaceutically acceptable salts thereof (e.g., magnesium stearate,steric acid, zinc stearate, palimitic acid, and sodium palitate).

It may also be useful to employ a charged lipid and/or detergentexcipient in the compositions. Suitable charged lipids include, withoutlimitation, phosphatidylcholines (lecithin), and the like. Detergentswill typically be a nonionic, anionic, cationic or amphotericsurfactant. Examples of suitable surfactants include, for example,Tergitol® and Triton® surfactants (Union Carbide Chemicals andPlastics); polyoxyethylenesorbitans, e.g., TWEEN® surfactants (AtlasChemical Industries); polysorbates; polyoxyethylene ethers, e.g., Brij;pharmaceutically acceptable fatty acid esters, e.g., lauryl sulfate andsalts thereof; ampiphilic surfactants (glycerides, etc.); and likematerials.

Other excipient materials can be added to alter porosity, for example,materials like sucrose, dextrose, sodium chloride, sorbitol, lactose,polyethylene glycol, mannitol, fructose, polyvinyl pyrrolidone orappropriate combinations thereof. Additionally, the anesthetic agent oragents may be dispersed with oils (e.g., sesame oil, corn oil,vegetable, soybean oil, castor oil, peanut oil), or a mixture thereofwith a phospholipid (e.g., lecithin), or medium chain fatty acidtriglycerides (e.g., Miglyol 812) to provide an oily suspension.

Still further excipient materials that can be incorporated into thecompositions include diluents of various buffer content (e.g., Tris-HCl,acetate); pH and ionic strength altering agents; additives such asantioxidants (e.g., ascorbic acid, glutathione, sodium metabisulfite);preservatives (e.g., Thimersol, benzyl alcohol, methyl paraben, propylparaben); and dispersing agents such as water-soluble polysaccharides(e.g., mannitol, lactose, glucose, starches), hyaluronic acid, glycine,fibrin, collagen and inorganic salts (e.g., sodium chloride).

In certain cases, the non-polymeric carrier is substantially insolublein water or in an aqueous biological system. Exemplary suchnon-polymeric carrier materials include, but are not limited to: sterolssuch as cholesterol, stigmasterol, β-sitosterol, and estradiol;cholestery esters such as cholesteryl stearate; C₁₂-C₂₄ fatty acids suchas lauric acid, myristic acid, palmitic acid, stearic acid, arachidicacid, behenic acid, and lignoceric acid; C₁₈-C₃₆ mono-, di- andtriacylglycerides such as glyceryl monooleate, glyceryl monolinoleate,glyceryl monolaurate, glyceryl monodocosanoate, glyceryl monomyristate,glyceryl monodicenoate, glyceryl dipalmitate, glyceryl didocosanoate,glyceryl dimyristate, glyceryl didecenoate, glyceryl tridocosanoate,glyceryl trimyristate, glyceryl tridecenoate, glycerol tristearate andmixtures thereof; sucrose fatty acid esters such as sucrose distearateand sucrose palmitate; sorbitan fatty acid esters such as sorbitanmonostearate, sorbitan monopalmitate and sorbitan tristearate; C₁₆-C₁₈fatty alcohols such as cetyl alcohol, myristyl alcohol, stearyl alcohol,and cetostearyl alcohol; esters of fatty alcohols and fatty acids suchas cetyl palmitate and cetearyl palmitate; anhydrides of fatty acidssuch as stearic anhydride; phospholipids including phosphatidylcholine(lecithin), phosphatidylserine, phosphatidylethanolamine,phosphatidylinositol, and lysoderivatives thereof, sphingosine andderivatives thereof; spingomyelins such as stearyl, palmitoyl, andtricosanyl spingomyelins; ceramides such as stearyl and palmitoylceramides; glycosphingolipids; lanolin and lanolin alcohols; andcombinations and mixtures thereof. Certain preferred non-polymericcarriers include cholesterol, glyceryl monostearate, glyceroltristearate, stearic acid, stearic anhydride, glyceryl monocleate,glyceryl monolinoleate, and acetylated monoglycerides.

If one of the above-noted non-polymeric carrier materials is selectedfor use in a composition, it will typically be combined with acompatible and suitable organic solvent for the carrier material to forma composition having a consistency ranging from watery to viscous to aspreadable putty or paste. The consistency of the composition will varyaccording to factors such as the solubility of the non-polymeric carrierin the solvent, the concentration of the non-polymeric carrier, theconcentration of the anesthetic agent and/or the presence of additionalanesthetic agents, additives and excipients. The solubility of anon-polymeric carrier in a particular solvent will vary according tofactors such as its crystallinity, hydrophilicity, ionic character andlipophilicity. Accordingly, the ionic character and the concentration ofthe non-polymeric carrier in the solvent can be adjusted to achieve thedesired solubility. Preferred non-polymeric carrier materials are thosethat have low crystallinity, nonpolar characteristics, and are morehydrophobic.

Suitable organic solvents for use in the compositions are generallythose that are biocompatible, pharmaceutically acceptable, and will atleast partially dissolve the non-polymeric carrier. The organic solventwill further have a solubility in water ranging from miscible to solubleto dispersible. In certain cases, the solvent is selected such that itis capable of diffusing, dispersing, or leaching away from thecomposition in situ in an aqueous system and into fluids found at theadministration site, thereby forming a solid implant. Preferably, thesolvent has a Hildebrand solubility parameter of from 9 to 13(cal/cm³)^(1/2). Preferably, the degree of polarity of the solvent iseffective to provide at least 5% solubility in water.

Suitable organic solvents thus include, but are not limited to:substituted heterocyclic compounds such as N-methyl-2-pyrrolidone (NMP)and 2-pyrrolidone (2-pyrol); esters of carbonic acid and alkyl alcoholssuch as propylene carbonate, ethylene carbonate and dimethyl carbonate;fatty acids such as acetic acid, lactic acid and heptanoic acid; alkylesters of mono-, di-, and tricarboxylic acids such as 2-ethyoxyethylacetate, ethyl acetate, methyl acetate, ethyl lactate, ethyl butyrate,diethyl malonate, diethyl glutonate, tributyl citrate, diethylsuccinate, tributyrin, isopropyl myristate, dimethyl adipate, dimethylsuccinate, dimethyl oxalate, dimethyl citrate, triethyl citrate, acetyltributyl citrate, glyceryl triacetate; alkyl ketones such as acetone andmethyl ethyl ketone; ether alcohols such as 2-ethoxyethanol, ethyleneglycol dimethyl ether, glycofurol and glycerol formal; alcohols such asethanol and propanol; polyhydroxy alcohols such as propylene glycol,polyethylene glycol (PEG), glycerin (glycerol), 1,3-butyleneglycol, andisopropylidene glycol (2,2-dimethyl-1,3-dioxolone-4-methanol); Solketal;dialkylamides such as dimethylformamide, dimethylacetamide;dimethylsulfoxide (DMSO) and dimethylsulfone; tetrahydrofuran; lactonessuch as F-caprolactone and butyrolactone; cyclic alkyl amides such ascaprolactam; aromatic amides such as N,N-dimethyl-m-toluamide, and1-dodecylazacycloheptan-2-one; and the like; and mixtures andcombinations thereof. Preferred solvents include N-methyl-2-pyrrolidone,2-pyrrolidone, dimethylsulfoxide, ethyl lactate, propylene carbonate,glycofurol, glycerol formal, and isopropylidene glycol.

In some cases, the organic solvent is present in an amount sufficient todissolve the active pharmaceutical agent in the composition. Forinstance, the organic solvent may be present in the composition in anamount of at least 5 wt %, such as at least 10 wt %, at least 15 wt %,or at least 20 wt %, based on weight of the composition. The organicsolvent may be present in the composition in an amount ranging from 5 wt% to 45 wt %, such as from 10 wt % to 35 wt %, from 15 wt % to 30 wt %,from 20 wt % to 25 wt %, or about 22 wt %, based on weight of thecomposition. The organic solvent may be provided in the composition inan amount of from 99.5 to 1 percent by weight relative to the totalweight of the composition (wt %), in an amount of from 95 to 10 wt %, inan amount of from 75 to 25 wt %, or in an amount of from 60 to 40 wt %,depending upon the selected non-polymeric carrier, organic solvent,anesthetic agent, additive and/or excipient being used in thecomposition. In certain cases, the organic solvent diffuses or leachesaway from the composition into an aqueous medium upon placement within abiological system, whereby the non-polymeric carrier material coagulatesto form a solid matrix. In certain cases, the organic solvent diffusesor leaches away from the composition into an aqueous medium uponplacement within a biological system, whereby the non-polymeric carriermaterial coagulates to form a semi-solid or gel. Preferably, thenon-polymeric carrier solidifies in situ to form a solid matrix within 1to 5 days after administration (implantation), preferably within 1 to 3days, preferably within 2 hours.

In some cases, a triglyceride viscosity reducing agent is present in anamount ranging from 10 wt % to 50 wt %, 10 wt % to 35 wt %, 15 wt % to30 wt %, or 20 wt % to 25 wt %, or about 15 wt %, 16 wt %, 17 wt %, 18wt %, 19 wt %, 20 wt %, 21 wt %, 22 wt %, 23 wt %, 24 wt %, 25 wt %, 27wt %, 28 wt %, 29 wt %, 30 wt %, 31 wt %, 32 wt %, 33 wt %, 34 wt %, or35 wt % of the composition.

In some cases, an aprotic solvent is present in an amount ranging from10 wt % to 35 wt %, 10 wt % to 30 wt %, 10 wt % to 20 wt %, 10 wt % to15 wt %, or about 2 wt %, 3 wt %, 4 wt %, 5 wt %, 6 wt %, 7 wt %, 8 wt%, 9 wt %, 10 wt %, 11 wt %, 12 wt %, 13 wt %, 14 wt %, 15 wt %, 16 wt%, 17 wt % 18 wt %, 19 wt %, or 20 wt % of the composition.

In some cases, compositions are provided wherein the non-polymericcarrier is a liquid. The liquid non-polymeric carrier is preferably ahigh viscosity liquid carrier material (“HVLCM”) to be non-watersoluble, and has a viscosity of at least 5,000 cP, (and optionally atleast 10,000, 15,000; 20,000; 25,000 or even 50,000 cP) at 37° C. thatdoes not crystallize neat under ambient or physiological conditions. Theterm “non-water soluble” refers to a material that is soluble in waterto a degree of less than one percent by weight under ambient conditions.The term “non-polymeric” refers to esters or mixed esters havingessentially no repeating units in the acid moiety of the ester, as wellas esters or mixed esters having acid moieties wherein functional unitsin the acid moiety are repeated a small number of times (i.e.,oligomers). Generally, materials having more than five identical andadjacent repeating units or mers in the acid moiety of the ester areexcluded by the term “nonpolymeric” as used herein, but materialscontaining dimers, trimers, tetramers, or pentamers are included withinthe scope of this term. When the ester is formed from hydroxy-containingcarboxylic acid moieties that can further esterify, such as lactic acidor glycolic acid, the number of repeat units is calculated based uponthe number of lactide or glycolide moieties, rather than upon the numberof lactic acid or glycolic acid moieties, where a lactide repeat unitcontains two lactic acid moieties esterified by their respective hydroxyand carboxy moieties, and where a glycolide repeat unit contains twoglycolic acid moieties esterified by their respective hydroxy andcarboxy moieties. Esters having 1 to 20 etherified polyols in thealcohol moiety thereof, or 1 to 10 glycerol moieties in the alcoholmoiety thereof, are considered nonpolymeric as that term is used herein.

In a particular case, the HVLCM decreases in viscosity, in some casessignificantly, when mixed with a solvent to form a low viscosity liquidcarrier material (“LVLCM”) that can be administered using standardmedical devices. The LVLCM composition is typically easier to place inthe body than a HVLCM composition, because it flows more easily into andout of syringes or other implantation means. It also can easily beformulated as an emulsion. The LVLCM can have any desired viscosity, butits viscosity is generally lower than the corresponding HVLCM. As anexample, viscosity ranges for the LVLCM of less than approximately 6,000cP, less than approximately 4,000 cP, less than approximately 1,000 cP,or less than 200 cP, are typically useful for in vivo applications.

The particular HVLCM used in the compositions can be one or more of avariety of materials. Suitable materials include nonpolymeric esters ormixed esters of one or more carboxylic acids. In a particular case, theester is formed from carboxylic acids that are esterified with a polyolhaving from 2 to 20 hydroxy moieties, and which may include 1 to 20etherified polyols. Particularly suitable carboxylic acids for formingthe acid moiety of the ester of the HVLCM include carboxylic acidshaving one or more hydroxy groups, e.g., those obtained by ring openingalcoholysis of lactones, or cyclic carbonates or by the alcoholysis ofcarboxylic acid anhydrides. Amino acids are also suitable for formingesters with the polyol. In a particular case, the ester or mixed estercontains an alcohol moiety having one or more terminal hydroxy moietiesthat have been esterified with one or more carboxylic acids obtained byalcoholysis of a carboxylic acid anhydride, such as a cyclic anhydride.

Nonlimiting examples of suitable carboxylic acids that can be esterifiedto form the HVLCM include glycolic acid, lactic acid, 8-hydroxycaproicacid, serine, and any corresponding lactones or lactams, trimethylenecarbonate, and dioxanone. The hydroxy-containing acids may themselves befurther esterified through the reaction of their hydroxy moieties withadditional carboxylic acid, which may be the same as or different fromother carboxylic acid moieties in the material. Suitable lactonesinclude, but are not limited to, glycolide, lactide, 8-caprolactone,butyrolactone, and valerolactone. Suitable carbonates include but arenot limited to trimethylene carbonate and propylene carbonate.

The alcohol moiety of the ester or mixed ester may be derived from apolyhydroxy alcohol having from 2 to 20 hydroxy groups, and as indicatedabove, may be formed by etherifying 1 to 20 polyol molecules. Suitablealcohol moieties include those derived by removing one or more hydrogenatoms from: monofunctional C₁-C₂₀ alcohols, difunctional C₁-C₂₀alcohols, trifunctional alcohols, hydroxy-containing carboxylic acids,hydroxy-containing amino acids, phosphate-containing alcohols,tetrafunctional alcohols, sugar alcohols, monosaccharides, anddisaccharides, sugar acids, and polyether polyols. More specifically,the alcohol moieties may include one or more of: dodecanol, hexanediol,more particularly, 1,6-hexanediol, glycerol, glycolic acid, lactic acid,hydroxybutyric acid, hydroxyvaleric acid, hydroxycaproic acid, serine,ATP, pentaerythritol, mannitol, sorbitol, glucose, fructose, sucrose,glucuronic acid, polyglycerol ethers containing from 1 to 10 glycerolunits, polyethylene glycols containing 1 to 20 ethylene glycol units.

In particular cases, at least one of the carboxylic acid moieties of theesters or mixed esters of the HVLCM comprise at least one oxy moiety Inan even more particular case, each of the carboxylic acid moietiescomprise at least one oxy moiety.

In another particular case, at least one of the carboxylic acid moietiesof the esters or mixed esters contains 2 to 4 carbon atoms. In an evenmore particular case, each of the carboxylic acid moieties of the estersor mixed esters contains 2 to 4 carbon atoms.

In another more particular case, at least one of the carboxylic acidmoieties of the ester or mixed ester has 2 to 4 carbon atoms andcontains at least one oxy moiety. In another more particular case, eachof the carboxylic acid moieties of the ester or mixed ester has 2 to 4carbon atoms and contains at least one oxy moiety.

In a particular case, the HVLCM may be sucrose acetate isobutyrate(SAIB) or some other ester of a sugar alcohol moiety with one or morealkanoic acid moieties.

In a particular case, the HVLCM has a structure selected from the groupconsisting of:

wherein R¹, R², R³, R⁴, R⁵, R⁶, R⁷, and R⁸ are independently selectedfrom the group consisting of hydrogen, alkanoyl, hydroxy-substitutedalkanoyl, and acyloxy-substituted alkanoyl;

wherein at least three of R¹, R², R³, R⁴, R⁵, R⁶, R⁷, and R⁸ are otherthan hydrogen; and

wherein when R¹, R², R³, R⁴, R⁵, R⁶, R⁷, and R⁸ are selected from thegroup consisting of acetyl and isobutyryl, at least three of R¹, R², R³,R⁴, R⁵, R⁶, R⁷, and R⁸ are acetyl;

wherein R¹, R², and R³ are independently selected from the groupconsisting of hydrogen, alkanoyl, hydroxy-substituted alkanoyl, andacyloxy-substituted alkanoyl and wherein n is between 1 and 20;

R¹—O—(CH₂)_(n)—O—R²  III:

wherein n is an integer between 4 and 8, and R¹ and R² are independentlyselected from the group consisting of hydrogen, alkanoyl,hydroxy-substituted alkanoyl, and acyloxy-substituted alkanoyl;

wherein in formulae IV and V, R¹, R², R³, R⁴, and R⁵ are independentlyselected from the group consisting of hydrogen, alkanoyl,hydroxy-substituted alkanoyl, and acyloxy-substituted alkanoyl;

wherein in formulae VI and VII, R¹, R², R³, R⁴, R⁵, and R⁶ areindependently selected from the group consisting of hydrogen, alkanoyl,hydroxy-substituted alkanoyl, and acyloxy-substituted alkanoyl;

wherein R¹, R², R³, and R⁴ are independently selected from the groupconsisting of hydrogen, alkanoyl, hydroxy-substituted alkanoyl, andacyloxy-substituted alkanoyl.

In each of formulae I through VIII, one or more of the alkanoyl,hydroxy-substituted alkanoyl, and acyloxy-substituted alkanoyl groupsmay comprise alkanoyl moieties having 2 to 6 carbon atoms, including thecarbonyl carbon. Moreover, in another more particular case, each offormulae I through VIII comprise at least one hydroxy-substituted oracyloxy-substituted alkanoyl moiety. In an even more particular case, atleast one of these hydroxy-substituted or acyloxy-substituted alkanoylmoieties comprise alkanoyl moieties having 2 to 6 carbon atoms,including the carbonyl carbon.

The acyl groups forming the acyloxy substituents of the HVLCM may be anymoiety derived from a carboxylic acid in accordance with the commonlyaccepted definition of the term “acyl.” More particularly, the acylgroups of the compositions may be of the form R⁹CO—, where R⁹ isoptionally oxy-substituted alkyl of 2-6 carbon atoms. Thisoxy-substitution may take the form of hydroxy substitution, orsubstitution with additional acyl moieties. For example, R⁹ may be anoligomer of oxy-substituted carboxylic acids, linked by ester bondingbetween the hydroxy of one acid and the carboxy of another acid. In amore particular example, R⁹ may comprise 1 to 5 lactide or glycolideunits, where a lactide unit contains two lactic acid moieties esterifiedtogether and a glycolide unit contains two glycolic acid moietiesesterified together. Alternatively, R⁹ may contain mixed lactide andglycolide units, or may contain mixed lactic acid and glycolic acid,without the presence of lactide or glycolide units.

Particular HVLCM materials include components according to formulae IIor III, wherein R¹, R², and R³ are independently lactoyl, polylactoyl,8-caproyl, hydroxyacetyl, or polyhydroxyacetyl, in particular,polylactoyl and 8-caproyl, or polylactoyl and polyhydroxyacetyl.

The use of relatively small chain (2 to 6 carbon atoms), oxy-substitutedcarboxylic acid moieties in the ester or mixed ester is advantageous.When these acid moieties are present in the form of oligomeric esters(i.e., a subsequent acid moiety joined to the previous acid moietythrough esterification of the subsequent carboxy with the previous oxy),hydrolysis of the material is considerably easier than for oligomersmade with more than 6 carbon atoms because the material is morehydrophilic. In general, for drug delivery it is desired that the HVLCMbe water insoluble, but it may be somewhat hydrophilic. In general,HVLCMs synthesized with more hydrophilic units (as determined by ahigher O:C ratio) will be expected to absorb water more rapidly anddegrade more quickly. For example, a HVLCM made by covalently linking 4moles of glycolide to one mole of glycerol will be expected to absorbwater more rapidly and degrade more quickly than a HVLCM made bycovalently linking 2 moles of glycolide and 2 moles of lactide to onemole of glycerol. Similar increases can be expected for more flexiblemolecules and for more branched, spherical molecules based on freevolume arguments. Use of flexible and branched molecules may also havethe benefit of lowering the viscosity of the LVLCM. Using carboxylicacids and/or polyols of different chain length and using carboxylicacids having oxy-substitution allows a precise control of the degree ofhydrophilicity and of the solubility of the resulting ester. Thesematerials are sufficiently resistant to dissolution in vivo that theyare able to provide a sustained release of a carried anesthetic agentinto the body accompanied or followed by oxy bonds hydrolyzing in vivo.

In an even more particular case, the HVLCM excludes the acetate andisobutyrate ester of sucrose having a ratio of acetate to isobutyrateacid moieties of 2:6. However, sucrose acetate isobutyrate ester havinga ratio of acetate to isobutyrate moieties of 2:6 is included within thescope for use in aerosol formulations. This material can be madeaccording to the procedures described in U.S. Pat. No. 2,931,802.

In general, suitable HVLCM esters can be made by reacting one or morealcohols, in particular one or more polyols, which will form the alcoholmoiety of the resulting esters with one or more carboxylic acids,lactones, lactams, carbonates, or anhydrides of the carboxylic acidswhich will form the acid moieties of the resulting esters. Theesterification reaction can be conducted simply by heating, although insome instances addition of a strong acid or strong base esterificationcatalyst may be used. Alternatively, an esterification catalyst such asstannous 2-ethylhexanoate can be used. The heated reaction mixture, withor without catalyst, is heated with stirring then dried, e.g., undervacuum, to remove any un-reacted starting materials and produce a liquidproduct. Sucrose acetate isobutyrates can be made by following theprocedures described in U.S. Pat. No. 2,931,802.

In this regard, the polyol can be viewed as an oligomerizationinitiator, in the sense that it provides a substrate for esterificationof carboxylic acids, in particular, of oligomers of lactide, glycolide,or other esterified hydroxy-substituted carboxylic acids.

In certain cases, the HVLCM can be mixed with a viscosity-loweringsolvent to form a lower viscosity liquid carrier material (LVLCM), whichcan then be mixed with the one or more anesthetic agent to be delivered,prior to administration. These solvents can be water soluble, non-watersoluble, or water miscible, and can include, acetone, benzyl alcohol,benzyl benzoate, N-(betahydroxyethyl) lactamidebutylene glycol,caprolactam, caprolactone, corn oil, decylmethylsulfoxide, dimethylether, dimethyl sulfoxide, 1-dodecylazacycloheptan-2-one, ethanol, ethylacetate, ethyl lactate, ethyl oleate, glycerol, glycofurol(tetraglycol), isopropyl myristate, methyl acetate, methyl ethyl ketone,N-methyl-2-pyrrolidone, MIGLYOLs® (esters of caprylic and/or capricacids with glycerol or alkylene glycols, e.g., MIGLYOL® 810 or 812(caprylic/capric triglycerides), MIGLYOL® 818 (caprylic/capric/linoleictriglyceride), MIGLYOL® 829 (caprylic/capric/succinic triglyceride),MIGLYOL® 840 (propylene glycol dicaprylate/caprate)), oleic acid, peanutoil, polyethylene glycol, propylene carbonate, 2-pyrrolidone, sesameoil, SOLKETAL ([±]-2,2-dimethyl-1,3-dioxolane-4-methanol),tetrahydrofuran, TRANSCUTOL® (diethylene glycol monoethyl ether,carbitol), triacetin, triethyl citrate, diphenyl phthalate, andcombinations thereof. Additionally, if the composition is to be appliedas an aerosol, e.g., for topical application, the solvent may be or mayinclude one or more propellants, such as CFC propellants liketrichlorofluoromethane and dichlorofluoromethane, non-CFC propellantslike tetrafluoroethane (R-134a), 1,1,1,2,3,3,3-heptafluoropropane(R-227), dimethyl ether, propane, and butane.

Particularly suitable solvents and/or propellants include benzylbenzoate, benzyl alcohol, triacetin, triethyl citrate, dimethylsulfoxide, ethanol, ethyl lactate, glycerol, glycofurol (tetraglycol),N-methyl-2-pyrrolidone, MIGLYOL® 810, polyethylene glycol, propylenecarbonate, 2-pyrrolidone, and tetrafluoroethane.

Other possible solvents include perfluorodecalin,perfluorotributylamine, methoxyflurane, glycerolformal,tetrahydrofurfuryl alcohol, diglyme, and dimethyl isosorbide.

When the composition is used as a LVLCM to administer the anestheticagent, it should contain a solvent that the HVLCM is soluble in. Incertain instances, the anesthetic agent is also soluble in the solvent.In still further instances, the solvent is a second anesthetic agent inwhich the first anesthetic agent is soluble. The solvent is preferablynon-toxic and otherwise biocompatible.

In certain cases, the solvent is at least water soluble, so that it willdiffuse quickly into bodily fluids or other aqueous environment uponadministration, causing the composition to coagulate and/or become moreviscous. In some cases, the solvent is not completely miscible withwater or bodily fluids so that diffusion of the solvent from thecomposition, and the corresponding increase in viscosity of thecomposition, are slowed. Suitable solvents that have this property, atleast to some extent, include benzyl benzoate, MIGLYOL® 810, benzylalcohol, and triethylcitrate. Benzyl alcohol can be particularlysuitable, as it also an anesthetic agent.

When esters of 1,6-hexanediol or glycerol are used as the HVLCM, somepossible solvents are ethanol, N-methylpyrrolidone, propylene carbonate,and PEG 400.

The solvent is typically added to the compositions in an amount in therange from 99.7 percent to 0.5 percent by weight relative to the totalweight of the composition (wt %), from 95 percent to 1 wt %, from 75 to10 wt %, or from 50 to 15 wt %. The solvent is typically present in thecomposition in an amount in the range from 55 percent to 10 wt %.

In still further cases, the composition includes a material that is notmiscible with the HVLCM, such that when combined with the HVLCMsingularly or in combination with a solvent for the HVLCM, the resultingcomposition forms an emulsion. Such emulsions may contain the HVLCM inthe dispersed phase, such as in the case of SAIB/MIGLYOL® mixtures thatare emulsified in water or glycerol, or they may contain the HVLCM as acomponent of the continuous phase, such as in the case of an aqueoussolution that is emulsified in the HVLCM or a solution of the HVLCM in awater immiscible solvent.

In some cases, the delivery vehicle or system contains a polyorthoesterpolymer and a polar aprotic solvent. Also disclosed are low viscositydelivery systems for administration of active agents. In some cases, thelow viscosity delivery systems comprise a polyorthoester polymer, apolar aprotic solvent and a solvent containing a triglyceride viscosityreducing agent.

Polyorthoesters useful for the compositions provided herein aregenerally composed of alternating residues resulting from reaction of adiketene acetal and a diol, where each adjacent pair of diketene acetalderived residues is separated by the residue of a reacted diol. Thepolyorthoester may comprise .alpha.-hydroxy acid-containing subunits,i.e., subunits derived from an alpha.-hydroxy acid or a cyclic diesterthereof, such as subunits comprising glycolide, lactide, or combinationsthereof, i.e., poly(lactide-co-glycolide), including all ratios oflactide to glycolide, e.g., 75:25, 65:35, 50:50, etc. Such subunits arealso referred to as latent acid subunits; these latent acid subunitsalso fall within the more general “diol” classification as used herein,due to their terminal hydroxyl groups. Polyorthoesters can be preparedas described, for example, in U.S. Pat. Nos. 4,549,010 and 5,968,543.Exemplary polyorthoesters suitable for use in the compositions providedherein are described in U.S. Pat. No. 8,252,304. The polyorthoester maybe of the type and/or made as described in U.S. Pat. Nos. 8,252,305 and10,213,510, which are herein incorporated by reference in theirentireties.

The mole percentage of .alpha.-hydroxy acid containing subunits,R.sup.1, generally ranges from 0 to 20 mol % of the total diolcomponents (R.sup.1 and R.sup.3 as provided below). In one or morecases, the mole percentage of .alpha.-hydroxy acid containing subunitsin the polyorthoester formulation is at least 0.01 mole percent.Exemplary percentages of .alpha.-hydroxy acid containing subunits in thepolymer are from 0 to 50 mole percent, or from 0 to 25 mole percent, orfrom 0.05 to 30 mole percent, or from 0.1 to 25 mole percent. Forexample, in one case, the percentage of .alpha.-hydroxy acid containingsubunits in the polymer is from 0 to 50 mole percent. In another case,the percentage of .alpha.-hydroxy acid containing subunits in thepolymer is from 0 to 25 mole percent. In yet another particular case,the percentage of .alpha.-hydroxy acid containing subunits in thepolymer is from 0.05 to 30 mole percent. In yet another case, thepercentage of .alpha.-hydroxy acid containing subunits in the polymer isfrom 0.1 to 25 mole percent. As an illustration, the percentage of.alpha.-hydroxy acid containing subunits may be 0, 1, 2, 3, 4, 5, 6, 7,8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 24,26, 27, 28, 29 or 30 mole percent, including any and all ranges lyingtherein, formed by combination of any one lower mole percentage numberwith any higher mole percentage number.

Exemplary polyorthoesters possess a weight average molecular weight of1000 Da to 200,000 Da, for example from 2,500 Da to 100,000 Da or from3,500 Da to 20,000 Da or from 4,000 Da to 10,000 Da or from 5,000 Da to8,000 Da. Illustrative molecular weights, in Da, are 2500, 5000, 5500,6000, 6500, 7000, 7500, 8000, 8500, 9000, 9500, 10,000, 20,000, 30,000,40,000, 50,000, 60,000, 70,000, 80,000, 90,000, 100,000, 120,000,150,000, 175,000 and 200,000, and ranges therein, wherein exemplaryranges include those formed by combining any one lower molecular weightas described above with any one higher molecular weight as providedabove, relative to the selected lower molecular weight.

In one particular case related to the polyorthoester in the deliverysystem, the polyorthoester has a molecular weight ranging from 2,500daltons to 10,000 daltons.

In some cases, the polyorthoester comprises 40% to 75%, 40% to 60%, 45%to 55%, 65 to 75%, or about 40%, 45%, 50%, 55%, 60%, 65%, 70%, or 75% byweight of the composition.

In some cases, a sustained-release delivery vehicle is a polymericformulation in the form of a semi-solid polymer formulation comprising apolyorthoester, the amide-type local anesthetic and a non-steroidalanti-inflammatory drug (NSAID). In some cases, the non-steroidalanti-inflammatory drug (NSAID) is an enolic-acid NSAID. Exemplaryenolic-acid NSAID include meloxicam, piroxicam, tenoxicam, droxicam,lornoxicam, and isoxicam. In a specific case, the enolic-acid NSAID ismeloxicam.

In some cases, a composition comprises:

-   -   1-5 wt % bupivacaine;    -   0.005-0.125 wt % meloxicam;    -   Optionally, maleic acid;    -   5-12 wt % dimethylsulfoxide or N-methylpyrrolidone;    -   10-40 wt % triacetin; and    -   55-67 wt % polyorthoester (e.g., having a Mw 2.5-10 kDa).

A number of suitable additives may be included with the composition inorder to impart selected characteristics upon the composition. Forexample, they may include a minor amount of a biodegradablethermoplastic polymer such as a polylactide, polycaprolactone,polyglycolide, or copolymer thereof, in order to provide a more coherentsolid implant or a composition with greater viscosity so as to hold itin place while it solidifies. Such thermoplastic polymers are disclosedin U.S. Pat. No. 4,938,763 to Dunn et al.

Optionally, a pore-forming agent can be included in the composition. Thepore-forming agent can be any organic or inorganic,pharmaceutically-acceptable substance that is substantially soluble inwater or body fluid, and will dissipate from the non-polymeric carriermaterial and/or the solid matrix of an implant into surrounding bodyfluid at the implant site. The pore-forming agent may preferably beinsoluble in the organic solvent to form a uniform mixture with thenon-polymeric carrier material. The pore-forming agent may also be awater-immiscible substance that rapidly degrades to a water-solublesubstance. In certain compositions, the pore-forming agent is combinedwith the non-polymeric carrier and organic solvent in admixture.Suitable pore-forming agents that can be used in the compositioninclude, for example, sugars such as sucrose and dextrose, salts such assodium chloride and sodium carbonate, polymers such ashydroxylpropylcellulose, carboxymethylcellulose, polyethylene glycol andpolyvinylpyrrolidone, and the like. Solid crystals that will provide adefined pore size, such as salt or sugar, are preferred.

As discussed above, a variety of additives can optionally be added tothe compositions to modify the properties thereof, and in particular tomodify the release properties of the composition with respect to theanesthetic agents contained therein. The additives can be present in anyamount sufficient to impart the desired properties to the composition.The amount of additive used will in general be a function of the natureof the additive and the effect to be achieved, and can be easilydetermined by the routineer. Suitable additives are described in U.S.Pat. No. 5,747,058, the entire contents of which are hereby incorporatedby reference. More particularly, suitable additives include water,biodegradable polymers, non-biodegradable polymers, natural oils,synthetic oils, carbohydrates or carbohydrate derivatives, inorganicsalts, BSA (bovine serum albumin), surfactants, organic compounds, suchas sugars, and organic salts, such as sodium citrate. In general, theless water soluble, i.e., the more lipophilic, the additive, the more itwill decrease the rate of release of the anesthetic agent, compared tothe same composition without the additive. In addition, it may bedesirable to include additives that increase properties such as thestrength or the porosity of the composition.

The addition of additives can also be used to lengthen the delivery timefor the anesthetic agent, making the composition suitable for medicalapplications requiring or responsive to longer-term administration.Suitable additives in this regard include those disclosed in U.S. Pat.Nos. 5,747,058 and 5,736,152. In particular, suitable additives for thispurpose include polymeric additives, such as cellulosic polymers andbiodegradable polymers. Suitable cellulosic polymers include celluloseacetates, cellulose ethers, and cellulose acetate butyrates. Suitablebiodegradable polymers include polylactones, polyanhydrides, andpolyorthoesters, in particular, polylactic acid, polyglycolic acid,polycaprolactone, and copolymers thereof.

When present, the additive is typically present in the compositions inan amount in the range from 0.01 percent to 20 percent by weight, moreparticularly from 0.1 percent to 20 percent by weight, relative to thetotal weight of the composition, and more typically, is present in thecomposition in an amount in the range from 1, 2, or 5 percent to 10percent by weight. Certain additives, such as buffers, are only presentin small amounts in the composition.

The following categories are nonlimiting examples of classes ofadditives that can be employed in the compositions.

One category of additives are biodegradable polymers and oligomers. Thepolymers can be used to alter the release profile of the anestheticagent to be delivered, to add integrity to the composition, or tootherwise modify the properties of the composition. Non-limitingexamples of suitable biodegradable polymers and oligomers include:poly(lactide), poly(lactide-co-glycolide), poly(glycolide),poly(caprolactone), polyamides, polyanhydrides, polyamino acids,polyorthoesters, polycyanoacrylates, poly(phosphazines),poly(phosphoesters), polyesteramides, polydioxanones, polyacetals,polyketals, polycarbonates, polyorthocarbonates, degradablepolyurethanes, polyhydroxybutyrates, polyhydroxyvalerates, polyalkyleneoxalates, polyalkylene succinates, poly(malic acid), chitin, chitosan,and copolymers, terpolymers, oxidized cellulose, or combinations ormixtures of the above materials.

Examples of poly(α-hydroxy acid)s include poly(glycolic acid),poly(DL-lactic acid) and poly(L-lactic acid), and their copolymers.Examples of polylactones include poly(ε-caprolactone),poly(δ-valerolactone) and poly(γ-butyrolactone).

While not wishing to be bound by any theory, it is believed that whenthe composition contains a biodegradeable polymer, a portion of thepolymer may precipitate or coagulate at the surface of the compositionas any included solvent diffuses away from the material afteradministration to the subject. The polymer may thus be added as arelease modifying agent to affect the release of the anesthetic agent oragents, or may be added as part of a composition containing pre-formedmicrospheres, implants, or ground polymer particles. The precipitationor coagulation of the polymer forms a skin at least partiallysurrounding the liquid core of such composition. This skin is porous,and allows the solvent to continue to diffuse through it intosurrounding tissue. The rate of solvent release and the extent offormation of the skin, as well as its porosity, can be controlled by theamount and type of solvent and polymer used in the composition.

Other additives for use with the present compositions arenon-biodegradable polymers. Non-limiting examples of nonerodiblepolymers which can be used as additives include: polyacrylates,ethylene-vinyl acetate polymers, cellulose and cellulose derivatives,acyl substituted cellulose acetates and derivatives thereof,non-erodible polyurethanes, polystyrenes, polyvinyl chloride, polyvinylfluoride, polyvinyl (imidazole), chlorosulphonated polyolefins,polyethylene oxide, and polyethylene.

Preferred non-biodegradable polymers include polyvinyl pyrrolidone,ethylene vinylacetate, polyethylene glycol, cellulose acetate butyrate(“CAB”) and cellulose acetate propionate (“CAP”).

A further class of additives which can be used in the presentcompositions are natural and synthetic oils and fats. Oils derived fromanimals or from plant seeds of nuts typically include glycerides of thefatty acids, chiefly oleic, palmitic, stearic, and linoleic. As a rulethe more hydrogen the molecule contains the thicker the oil becomes.

Non-limiting examples of suitable natural and synthetic oils includevegetable oil, peanut oil, medium chain triglycerides, soybean oil,almond oil, olive oil, sesame oil, fennel oil, camellia oil, corn oil,castor oil, cotton seed oil, and soybean oil, either crude or refined,and medium chain fatty acid triglycerides.

Fats are typically glyceryl esters of higher fatty acids such as stearicand palmitic. Such esters and their mixtures are solids at roomtemperatures and exhibit crystalline structure. Lard and tallow areexamples. In general oils and fats increase the hydrophobicity of anon-polymeric carrier system, slowing degradation and water uptake.

Any of the above-described sustained release delivery systems can beformulated as liquid, spray, cream, lotion, ointment, gel, slurry, oil,emulsion, microemulsion, solid, plaster, film, particle, microparticle,powder or other suitable form pharmaceutical compositions, suitable foruse in the methods. In such compositions, the anesthetic agent (e.g.,the first anesthetic agent) is included in an amount sufficient todeliver to the subject to be treated an effective amount to achieve adesired effect. The amount of anesthetic agent incorporated into thecomposition depends upon the final desired release duration and profile,and the concentration of anesthetic required for the intended effect.

Both soluble and insoluble anesthetic agents can be distributed usingthe non-polymeric carrier materials for sustained delivery. Moreover,the compositions may be further formulated with polymeric excipients toprovide a delivery matrix with modified properties, for example a fasteror slower degradation rate. The resulting composition may be formed intomicrospheres, or into a macroscopic implant, or other geometries andsizes according to techniques known in the art. Alternatively, apre-formed microsphere, implant, or polymer particle with the anestheticagent or agents incorporated therein can be combined with thenon-polymeric carrier.

Microspheres may be prepared by a number of methods known in the art, aswell as methods described in U.S. Pat. Nos. 6,291,013 and 6,440,493. Thepolymer particle may be formed using melt extrusion, granulation,solvent mixing, absorption, or like techniques, or the anesthetic agentmay be adsorbed onto a polymer matrix, such as an ion exchange resin.The resulting material, when combined suitable non-polymeric carriermaterial may be administered parenterally. In other cases, theanesthetic agent may be combined with a non-polymeric material, such ascalcium phosphate or sucrose, to provide layering/barrier propertiesthat lengthen degradation. The non-polymeric carrier will then form asecondary barrier to provide enhanced delivery characteristics. Thenon-polymeric carrier phase may or may not contain other biologicallyactive substances, according to the specific requirement of the selectedapplication. These other biologically active agents may be any suitabletherapeutic and/or prophylactic pharmaceutical, provided that the addedsubstance is suitable for incorporation into microspheres or implantsaccording to techniques known in the art.

All of the above-described compositions may be used in the methods ofthe present disclosure in order to provide sustained local anesthesia ata target site. In particular, the compositions may be formulated asliquid, spray, cream, lotion, ointment, gel, slurry, oil, emulsion,microemulsion, solid, plaster, film, particle, microparticle, powder orany other suitable pharmaceutical composition form and then administeredto a subject via topical, ophthalmic, transdermal, parenteral (e.g,injection, implant, etc.) or like delivery techniques. The compositions,containing an anesthetic and a pharmaceutically acceptable non-polymericcarrier, are used to provide an anesthetic effect characterized bysustained local anesthesia after administration to the subject withoutan initial burst and a duration of at least 24 hours afteradministration, preferably 36 to 48 hours after administration, and morepreferably 48 to 72 hours after administration. In certain cases, theonset of the local anesthesia occurs within 2 hours of administration tothe subject, preferably within 1 hour of administration, and in somecases within 30 minutes of administration to the subject.

The term “subject,” as used herein, refers to any vertebrate in which itis desired to provide a state of local anesthesia. The term thus broadlyrefers to any animal that is to be treated with the compositions of thepresent disclosure, such as birds, fish and mammals including humans. Incertain cases, the methods of the present disclosure are suitable toprovide sustained anesthesia in veterinary practice and animalhusbandry, e.g., birds and mammals, whenever a long-term state of localanesthesia is convenient or desirable. In certain cases, thecompositions are particularly suited for used with companion animalssuch as dogs or cats, and additionally may be used with horses. Inpreferred cases, the term “subject” intends a human subject.Furthermore, the term “subject” does not denote a particular age, andthe compositions are thus suited for use with subjects of any age, suchas infant, adolescent, adult and senior aged subjects.

In preferred cases, the compositions of the present disclosure areparticularly suited for use in the treatment of wounds. Thenon-polymeric carrier systems allow the anesthetic agent or agents to beeasily applied to the wound, either directly within the wound and/oradjacent to the wound, using very simple application techniques suchdropping on, spraying, painting, spreading, molding or otherwisemanually manipulating a liquid, spray, cream, lotion, ointment, gel,slurry, oil, emulsion, microemulsion, pliable solid or plaster, film,particle, microparticle, or powder composition into the wound. Thecompositions can thus be used with any sized or shaped wound, and willprovide an even distribution of the anesthetic agent or agents over theentire area of the wound for better retention and efficacy. Wounds thatcan be treated using such methods my range for the most superficial todeep, from surface to incisional and from surgical (or otherwisedeliberate) to accidental. If the composition is to be injected, it maybe applied to the subcutaneous space using a trailing injectionalongside the wound on all sides or outside boundaries. Combinationapproaches may also be employed, such as where the composition is bothlaid directly into the wound, e.g., prior to surgical closure of thesound, and additionally along the wound. In a particularly preferredcase, the methods of the present disclosure involve the use of theinstant compositions as a local anesthetic for treatment ofpost-operative incisional pain. Use of the present compositions in thismanner may obviate or at least mitigate the necessity to provide adjuncttherapies, such as the administration of systemic narcotic analgesics inorder to treat such post-operative pain. Accordingly, the compositionsmay be used to treat post-operative pain that accompanies all types ofmedical procedures, such as major surgeries (e.g., thoracotomy, aorticrepair, bowel resection), intermediate surgeries (e.g., cesareansection, hyseterectomy and appendectomy), and minor surgeries(laparoscopy, arthroscopy, and biopsy procedures), that can otherwise bedebilitating and may require pain treatment for 3 to 5 days aftersurgery. In some cases, methods produce analgesia in a subjectundergoing at least one of arthroscopic subacromial decompressionsurgery, laparoscopic surgery, arthroscopic surgery, biopsy surgery,bony surgery, orthopedic surgery, thoracic surgery, soft tissue surgery,cholecystectomy surgery, colorectal surgery, colectomy surgery,hyseterectomy surgery, appendectomy surgery, bunionectomy surgery,hemorrhoidectomy surgery, Casesarean section surgery, total kneearthroplasty surgery, abdominoplasty surgery, nerve block, herniorrhaphysurgery, hernia surgery, inguinal hernia repair surgery, resection liversuregery, resection of small bowel surgery, resection of stomachsurgery, resection of spleen surgery, resection of gall bladder surgery,and resection of colon surgery.

The compositions described herein can thus be administered in thepractice of the instant methods using a wide variety of methods. Forexample, the compositions may be administered topically, ophthalmically,systematically (for example, mucosally (orally, rectally, vaginally, ornasally), parenterally (intravenously, subcutaneously, intramuscularly,or intraperitoneally), or the like. The compositions may be applied viainjection, pouring, spray dip, aerosol, or coating applicator. Aerosolsor mists of the composition can be administered using an aerosolpropellant, e.g., for topical administration, or using a suitablenebulizer, e.g., for nasal, or oral mucosal administration.

Preferably, the compositions are administered as liquids via injection,or in an aerosol, paste or emulsion. When used in an aerosol, anysolvent present in the aerosol solution will typically evaporate uponapplication, allowing the composition to set-up as a film.Alternatively, the aerosol or emulsion may be prepared without asolvent. In this situation, the aerosol propellant can also function asa solvent. Formation of aerosols and emulsions can be accomplished usingtechniques known to those skilled in the art. See, for example, Ansel,H. C. et al., Pharmaceutical Dosage Forms and Drug Delivery Systems,Sixth Edition (1995).

In addition to the uses described above, the present compositions can beadministered through osmotic pumps. In one case, a device is designed tobe implanted in the tissue of the subject, and designed to effectsustained release over time.

It is also possible to administer the compositions using a porous ornonporous tube, desirably made of extruded biodegradeable polymer. Thetube may be prepared with varying degrees of porosity depending on thecharacteristics of the composition and the release characteristicsdesired. The composition is inserted into the tube, and the ends of thetube may be left open, allowing biologically active compound to diffuseout of the ends of the tube, or may be closed off with additional porousor nonporous polymer. Porous endcaps and porous tubes allow activecompound to diffuse through the pores over time. Nonporous endcaps, aswell as nonporous tubes, allow anesthetic agents that are soluble in thepolymer to diffuse through it and into surrounding tissues. Nonporousmaterials that are not solvents for the anesthetic, but that arebiodegradable, will release the anesthetic when they degradesufficiently. The compositions may be prepared and stored asmulti-component systems until ready for administration. The number ofdifferent components will depend, in part, on the characteristics of thecomposition. Prior to administration, the components are combined andmixed, e.g., to achieve a homogeneous composition, which can then beadministered to the subject. Solvents or additives may be added to oneor all of the components, or may form a separate component, which isalso mixed with the others prior to administration. Separation of thecomposition into a multicomponent mixture allows the storage conditionsfor each component to be optimized, and minimizes any detrimentalinteractions between components over time. The result is increasedstorage stability.

EXAMPLES

The below examples are offered for illustrative purposes only, and arenot intended to limit the scope of the present invention in any way.

Example 1

A gamma irradiation dose escalation study was conducted in which thelevel of the genotoxic degradant, 2,6-dimethylaniline, increased as afunction of irradiation dose. A formulation was exposed to 0, 10, 20, or35 kGy. The formulation consisted of 12 wt % bupivacaine, 66 wt % SAIB,and 22 wt % benzyl alcohol (“Formulation A”).

As discussed below, even low level irradiation (10 kGy) of the productgenerated significant amounts of 2,6-dimethylaniline.

Abstract

Formulation A after terminal sterilization by gamma irradiation atnominal exposures of 10, 20, and 35 kGy showed color changes (lightyellow to yellow), an increase of the major degradant bupivacaineN-oxide from 0.27% to 0.43-0.53%, an increase of the degradant2,6-dimethylaniline (2,6-DMA) from a non-detected level to 0.02-0.08%(or 75-302 parts per million, or ppm), and an increase of unknown drugrelated degradant peaks from 2 peaks to 4-12 peaks, while the potencydecreased from 98.9% to 96.1-97.1%, as determined by reverse phase HPLC.

Stability of Formulation A at 0, 10, 20, and 35 kGy was monitored at 25°C./60% RH and 40° C./75% RH for up to 20 months. The formulation colorcontinued to darken from yellow to brown at 25° C./60% RH and became adarker brown at 40° C./75% RH. After 20 months at 25° C./60% RH, datafrom HPLC for the different irradiated groups showed an insignificantdecrease in potency from the corresponding initial T=0 timepoint, aslight increase (0.09-0.19%) in bupivacaine N-oxide, no significantincrease in 2,6-DMA, and a small increase (0.09-0.17%) in the totalamount of degradants. The control and 10 kGy exposed formulations showeda slight increase in the numbers of unknown detected peaks compared tothat of the 20 and 35 kGy exposed formulations.

Objective

The objective of this study was to evaluate the effect of differentexposure levels of gamma irradiation on the stability of Formulation A.The target nominal dose levels of gamma irradiation were 10, 20, and 35kGy, with a control that was not irradiated (0 kGy).

Background and Introduction

The composition of Formulation A was bupivacaine base/sucrose acetateisobutyrate (SAIB)/benzyl alcohol (BA) at a % w/w ratio of 12/66/22,respectively. An unfiltered lot was filled into 200 vials, capped withnon-siliconized Teflon stoppers, and sealed with aluminum crimp seals.The 200 vials were further divided into four groups of 50 vials each.One group was not irradiated, and the remaining three groups wereterminally sterilized by gamma irradiation at 10, 20, and 35 kGy,respectively. All four groups were placed on stability at 25° C./60% RHand 40° C./75% RH in an upright position. A placebo lot exposed tosimilar gamma irradiation conditions as the active lot was used toidentify those impurities related to the excipients, which weretherefore excluded from the drug related degradant calculations.

The effect of gamma irradiation dose escalation was evaluated by avisual method and EP (European Pharmacopoeia) 2.2.2 (degree ofcoloration), and by HPLC. Tests were conducted on stability samples at 6and 20 months at 25° C./60% RH, and at 3 and 20 months at 40° C./75% RH.Compositions of bupivacaine/sucrose acetate isobutyrate/benzyl alcoholexhibited a light yellow coloration prior to gamma irradiation. Visualinspection and characterization by EP 2.2.2 was conducted to assess theextent to which the compositions formed darker yellow to browncoloration.

2,6-DMA is a potential genotoxic degradant resulting from degradation ofthe drug substance or drug product by hydrolysis of the amide bond inbupivacaine. Since 2,6-DMA exhibits a different response factor (RF)from that of bupivacaine, its relative response factor (RRF) from systemsuitability (SYS) solution injections was applied to convert the %2,6-DMA value by peak area normalization to 2,6-DMA as expressed as ppmrelative to bupivacaine base.

Scope

Physical and chemical stability data were generated for Formulation Aafter exposure to gamma irradiation at levels of 0 kGy (control), 10 kGy(9.1_(min)-10.1_(max)), 20 kGy (19.2_(min)-22.0_(max)), and 35 kGy(31.7_(min)-36.0_(max)). The stability of non-irradiated and gammairradiated Formulation A samples was determined for up to 20 months at25° C./60% RH and 40° C./75% RH. The product was characterized forvisual appearance, visual color, potency and degradation products.Placebo vials were stored under the same conditions as that for theactives, and were tested to identify potential excipient relateddegradants that may form in the active Formulation A. These placeboexcipient degradants were excluded from the degradation productcalculations for Formulation A.

Equipment, Materials and Analytical Methods

The equipment and material used in this study are listed in the belowTable 1.1.

TABLE 1.1 Items Vendor / Model Bupivacaine Base Orgamol Benzyl AlcoholJT Baker Sucrose Acetate Isobutyrate DURECT Corporation (SAIB) ContainerWest Pharmaceutical, 10 mL Type 1 borosilicate glass vial BupivacaineBase Reference Orgamol Standard Bupivacaine N-Oxide Chemic Lab IncStandard Benzaldehyde Aldrich 2,6-Dimethylaniline (DMA) Spectrum BenzylAcetate Aldrich Benzyl Isobutyrate Aldrich EP color standards FlukaStopper West Pharmaceutical, 20 mm, 4432/50 gray, non-silconized Teflonfaced rubber stopper Seal West Pharmaceutical, 20 mm flip off aluminumcrimp seal HPLC System Agilent 1100 series

Results and Discussion

Appearance (Clarity)

There was no noticeable change in solution clarity for non-irradiatedand irradiated Formulation A at T=0 and on storage at both 25° C./60% RHand 40° C./75% RH for up to 20 months.

Degree of Coloration

Formulation A was exposed to different target irradiation levels (0, 10,20, and 35 kGy). Table 1.2 summarizes the results for the formulationcolor changes due to the gamma-irradiation process, and after storage at25° C./60% RH and 40° C./75% RH for up to 20 months.

TABLE 1.2 Degree of Coloration Visual Test for Formulation A Exposed toNominal Gamma Irradiation Levels of 0, 10, 20 and 35 kGy Stored at 25°C./60% RH and 40° C./75% RH up to 20 Months Using EP 2.2.2 Lot 1.1 DoseLevel of Gamma Irradiation / EP reference Standard BY^(1,2) ConditionMonth³ 0 kGy 10 kGy 20 kGy 35 kGy 25° C./60% RH⁴ 1 BY3 BY1 >BY1 >BY1Lightly yellow Yellow++ Darker yellow Darker Yellow 25° C./60% RH⁴3 >BY3 >BY1 >BY1 >BY1 Light yellow+ Darker yellow Darker yellow Darkeryellow 25° C./60% RH⁴ 6 >BY2 >BY1 >BY1 >BY1 Yellow+ Darker yellow Darkeryellow Darker yellow 25° C./60% RH 20⁵  >BY1 <BO <BO BO Darker yellowLightly brown yellow Lightly brown yellow Lightly brown yellow 40°C./75% RH 1 BY2 >BY1 <BO BO Yellow Darker yellow Lightly brown yellowBrown yellow 40° C./75% RH 3 >BY1 BO BO BO Darker yellow Brown yellowBrown yellow Brown yellow 40° C./75%RH 20⁵  <BX BX BX BX Lightly darkbrown Dark brown Dark brown Dark brown ¹EP standard BY series colorranking: BY1 (yellow) > BY2 (yellow) > BY3 (light yellow)²Non-compendias standards from Fluka: BO = brown yellow, BX = darkbrown. BX is a darker color than BO. ³1-month data results served asinitial data. ⁴Color ranking (BY1) for irradiated Formulation A:BY1_(35 kGy) > BY1_(20 kGy) > BY1_(10 kGy) ⁵Performed after vials werepulled and stored at ambient temperature for approximately 2 months.

Effect of Gamma-Irradiation

The results indicate that gamma irradiation increased the color in theformulations from light yellow (non-irradiated formulation) to yellow(exposed to irradiation), with each higher level of irradiation causinga darker yellow color.

Effect of Storage at 25° C./60% RH and 40° C./75% RH

For all 4 groups of formulation, the degree of coloration increased withtime at both storage conditions, and the accelerated condition (40°C./75% RH) darkened the formulation color faster than that at 25° C./60%RH.

After 20 Months Storage:

Non-irradiated formulation changed color from light yellow (BY3) todarker yellow (>BY1) at 25° C./60% RH, and to dark brown (<BX) at 40°C./75% RH.

-   -   10 kGy exposed formulation changed color from yellow (BY1) to        brown (<BO) at 25° C./60% RH, and to dark brown (BX) at 40°        C./75% RH.    -   20 kGy exposed formulation changed color from darker yellow        (>BY1) to brown (<BO) at 25° C./60% RH, and to dark brown (BX)        at 40° C./75% RH.    -   35 kGy exposed formulation changed color from darker yellow        (>BY1) to brown (BO) at 25° C./60% RH, and to dark brown (BX) at        40° C./75% RH.

Potency

Effect of Gamma Irradiation on Formulation A Stability

As shown in Table 1.3, the potency (% LS) of Formulation A at T=0 wasaffected by gamma irradiation. The % LS of Formulation A was 98.9%,97.1%, 96.1% and 96.2% after target irradiations of 0, 10, 20 and 35kGy, respectively.

TABLE 1.3 Potency and Degradation Products Stability Testing forFormulation A Exposed to Nominal Gamma Irradiation Levels of 0, 10, 20and 35 kGy and Analyzed by HPLC % Mean Degradation Products (alldetected peaks) 2,6-Dimethylaniline (2,6-DMA) Total Number % MeanIrradiation % (by Peak of Unknown Label Storage Dose Bupivacaine Areappm (to Detected Peaks Strength Condition Time (kGy)¹ N-oxideNormalization) Bupivacaine)² (each <0.1%) Bupivacaine Initial 0 0 0.27Not Detected Not Detected  2 peaks 98.9 10 0.43 0.02  75  4 peaks 97.120 0.51 0.05 189  9 peaks 96.1 35 0.53 0.08 302 12 peaks 96.2 25° C./60%RH  6 months 0 0.31 Not Detected Not Detected  3 peaks 96.2 10 0.54 0.05189  6 peaks 96.7 20 0.61 0.06 226  8 peaks 95.8 35 0.60 0.08 302  8peaks 94.6 20 months 0 0.36 Not Detected Not Detected  5 peaks 98.5 100.61 0.03 113 10 peaks 97.5 20 0.70 0.06 226  9 peaks 97.0 35 0.63 0.08302 10 peaks 96.6 40° C./75% RH  3 months 0 0.23 Not Detected NotDetected  4 peaks 97.1 10 0.47 0.04 151  5 peaks 95.9 20 0.52 0.07 264 7 peaks 95.5 35 0.45 0.09 340  7 peaks 95.3 20 months 0 0.79 0.01⁴  3810 peaks 97.3 10 0.72 0.04 151 13 peaks 96.8 20 0.57 0.07 264 12 peaks96.1 35 0.47 0.09 340 12 peaks 96.0 ¹The actual dose range for thenominal 10 kGy exposure was 9.1 to 11.1 kGy, for the nominal 20 kGyexposure it was 19.2 to 22.0 kGy, and for the nominal 35 kGy exposure itwas 31.7 to 36.0 kGy. ²Calculation for ppm 2,6-DMA = % 2,6-DMA (by areanormalization) × 10000/relative response factor (2.65). This relativeresponse factor was determined for HPLC. Note that the results in thisTable are reported as “ppm (to bupivacaine).” To convert from “ppm (tobupivacaine)” to ppm relative to total formulation, the above numbersshould be multiplied by 0.12 considering that Formulation A comprises 12wt % bupivacaine.

Stability at 25° C./60% RH and 40° C./75% RH

No significant changes in % LS were observed for non-irradiatedFormulation A and the three groups of irradiated formulations after 20months storage at 25° C./60% RH compared to their corresponding T=0% LSvalues. After 20 months at 40° C./75% RH (the commercial product wouldnot be stored under these conditions), the non-irradiated formulationpotency decreased from 98.9% to 97.3%, while the gamma irradiated groupshad no significant potency changes.

Degradation Products

Irradiation Effect on Formulation A at T=0

The major degradant, bupivacaine N-oxide, is formed by the oxidation ofthe amine group in bupivacaine. Table 1.3 lists the amounts of 2,6-DMAand bupivacaine N-oxide, and the total number of unknown detected peaksresulting from the gamma irradiation process for all four formulationgroups.

2,6-DMA

The results show that for the non-irradiated Formulation A samples,2,6-DMA was not detected by HPLC. However, as irradiation levelsincreased, the mean % 2,6-DMA increased to 0.02% (75 ppm) at 10 kGyexposure, 0.05% (189 ppm) at 20 kGy exposure, and 0.08% (302 ppm) at 35kGy exposure.

Bupivacaine N-oxide

The irradiation process at T=0 also increased the % bupivacaine N-oxidefrom 0.27% to 0.43%, 0.51% and 0.53% for samples exposed to 10, 20, and35 kGy, respectively. The presence of bupivacaine N-oxide was confirmedby matching the retention time with the authentic material.

Total Number of Unknown Detected Peaks

The irradiation process increased the total of unknown degradation peaks(each ≤0.1%) from 2 peaks at 0 kGy to 4, 9, and 12 peaks at 10, 20, and35 kGy, respectively.

Total Degradation Products

The irradiation process increased the % total degradation products from0.33% (non-irradiated) to 0.61% (10 kGy exposure), 0.87% (20 kGyexposure), and 0.94% (35 kGy exposure).

Irradiation Effect on Formulation A Stability at 25° C./60% RH

2,6-DMA

The 2,6-DMA was not detected in the non-irradiated Formulation A samplesfor up to 20 months at 25° C./60% RH (Table 1.3). The levels of 2,6-DMAin the irradiated samples did not significantly change during stabilityat 25° C./60% RH for up to 20 months.

Bupivacaine N-Oxide

There was a slight increase in the bupivacaine N-oxide by approximately0.1 to 0.2% for each group after 20 months storage at 25° C./60% RH(Table 1.3).

Total Degradation Products

There was an insignificant increase of approximately 0.1 to 0.2% in thetotal amount of degradation products in each of the four groups after 20months at 25° C./60% RH, as compared to the corresponding values at T=0.

Irradiation Effect on Formulation A Stability at 40° C./75% RH

2,6-DMA

The non-irradiated Formulation A samples after 3 months at 40° C./75% RHhad no detectable amount of 2,6-DMA (Table 1.3). After 20 months at 40°C./75% RH, the non-irradiated samples had 0.01% (38 ppm) of 2,6-DMA. Forthe three irradiated groups of samples, the 2,6-DMA increased slightly(0.01 to 0.02%) from their respective T=0 values during storage at 40°C./75% RH. The final levels of 2,6-DMA after 20 months at 40° C./75% RHwere 0.04% (151 ppm) in the 10 kGy-exposed samples, 0.07% (264 ppm) inthe 20 kGy exposed samples, and 0.09% (340 pm) in the 35 kGy exposedsamples.

Bupivacaine N-Oxide

The major degradant, bupivacaine N-oxide, increased from 0.27% to 0.79%in the non-irradiated samples, and increased from 0.43% to 0.72% in the10 kGy exposed samples after 20-months storage at 40° C./75% RH (Table1.3). There was no significant change in the bupivacaine N-oxide levelsfor the 20 and 35 kGy irradiated samples after 20-months at 40° C./75%RH.

Total Degradation Products

The data indicated that the % total degradants increased from 0.33% to0.99% for the non-irradiated samples, and increased from 0.61% to 1.01%for the 10 kGy irradiated samples, after 20 months at 40° C./75% RH. Thetotal degradants remained the same for the 20 kGy irradiated samples,and appeared to decrease slightly for the 35 kGy irradiated samplesafter 20 months at 40° C./75% RH.

Potency and Degradation Products at 20 Months

All four groups of Formulation A samples stored at both 25° C./60% RHand 40° C./75% RH for 20 months were also analyzed by HPLC for potencyand degradation products. Similar trends in the % LS bupivacaine, %2,6-DMA, % bupivacaine N-oxide, and % total degradants in the fourgroups of Formulation A were observed as that by HPLC.

Conclusion

The gamma irradiation exposure levels and storage conditions(temperature and time) affected both the degree of solution colorationand chemical stability of Formulation A. The formulation color changedfrom light yellow (before irradiation) to yellow (irradiation range 10to 35 kGy), and to brown/dark brown (under typical stability storageconditions). Acceptable bupivacaine potency stability (% LS) wasobserved at 25° C./60% RH and 40° C./75% RH for up to 20 months for boththe non-irradiated and irradiated samples. The gamma irradiation processinduced the potential genotoxic degradant 2,6-DMA.

Example 2

Formulation A was made aseptically by the following process:

1. Add benzyl alcohol to mixing tank and heat to 40° C. (not to exceed55° C.).2. While mixing benzyl alcohol under slight vortex, add in pre-weighedbupivacaine base.3. Mix for not less than 15 minutes.4. Heat SAIB to approximately 60° C. (not to exceed 93° C.).

5. Weigh in SAIB.

6. Mix for not less than 45 minutes.7. Perform in-process potency and bioburden testing.8. Pressurize the tank with nitrogen gas to force the mixture throughtwin-series, 30″, 0.22 fLm, sterilizing grade filters.9. Fill the product into 10 mL glass vials.10. Stopper the vials with 20 mm stoppers under a nitrogen environment.11. Cap the vials with 20 mm aluminum crimp caps.12. Inspect each vial.13. Label and package as appropriate.

Two lots of the resulting formulation had good stability as shown inTable 2.1 and Table 2.2.

TABLE 2.1 Stability Data Formulation A, Stored at 25° C./60% RH and 40°C./75% RH (Lot # 2.1, 7.5 mL) Initial¹ 40° C./75% RH 25° C./60% RH Tests(Acceptance Criteria) 0 1 month 2 months 3 months 3 months AppearanceClear Clear Clear Clear Clear solution solution solution solutionsolution Assay (Release) ² 98.6 99.1 98.3 97.5 97.6 (95.0-105.0% LabelStrength) (99.3, 99.4, (99.8,98.9, 97.1, 98.9, (97.4, 97.4, (97.8, 97.5,Assay (Shelf-life) ² 98.5, 98.1 98.5) 98.8) 97.6) 97.6) (90.0-105.0%Label Strength) 98.5, 98.1) Individual Degradants³ (Bupivacaine N-oxide≤2.0%, all other individuals ≤0.2% by Area Normalization) 1) BupivacaineN-oxide 0.2 0.3 0.3 0.3 0.2 2) 2,6-Dimethylaniline n.d. n.d. n.d. n.d.n.d. Total Degradation Products ⁴ 0.2 0.3 0.3 0.3 0.2 (≤3.0% by Areanormalization) Drug Release (Criteria) % Cumulative Release Average(Range)  1 hr (0-10% of target) 6 (5-6)  5 (5-6)  6 (5-6)  6 (5-7)  6(5-6)   4 hr Report value 17 (15-18) 17 (17-18) 17 (17-17) 17 (17-18) 17(16-18)  8 hr Report value 26 (23-28) 27 (26-27) 26 (26-27) 27 (26-27)27 (26-27) 12 hr Report value 37 (32-40) 37 (35-39) 37 (36-39) 35(34-37) 36 (35-36) 18 hr (40-70% of target) 54 (49-58) 55 (53-58) 55(54-57) 51 (48-54) 53 (52-54) 24 hr Report value 68 (64-71) 68 (66-71)67 (65-70) 63 (60-66) 66 (64-68) 36 hr Report value 85 (83-87) 85(83-86) 85 (83-86) 81 (79-84} 84 (82-86) 48 hr Report value 89 (88-91)89 (87-90) 89 (87-89) 88 (86-89) 89 (88-90) 72 hr (75-105% of target) 93(91-96) 92 (90-94) 92 (89-93) 90 (88-92) 90 (88-92) Degree of ColorationBY4 BY2 BY1 Darker than RY2 (Record results) BY1 Volume in Container ⁵9.3-9.6 Test not Test not Test not Test not (NLT 7.5 mL) performedperformed performed performed Bacteria toxins <24 Test not Test not Testnot Test not (≤25 EV/mL); performed performed performed performedParticular Matter, Microscopy (≥10 μm: ≤3000 particles/vial) 103, 110 224 16 183 (≥25μm: ≤3000 particles/vial) 25, 31 5 1 3 29 Sterility (meetsUSP/EP) Pass Test not Test not Test not Test not performed performedperformed performed ¹Data at T = 0 are average of duplicate sets ofsamples. All other time points are average of one set of samples. ²Average and individual assay values are reported. ³Average values fordegradants are reported. The excipient related degradation products(benzyl acetate and benzyl isobutyrate) are not reported in this table.Not detected (n.d.). ⁴ The total degradation products are based on thesum of all individual degradants at or greater than 0.1%. Average valuesare reported. ⁵ The range of values is reported.

TABLE 2.2 Stability Data Formulation A Stored at 25° C./60% RH and 40°C./75% RH (Lot #2.2, 5 mL fill) Initial¹ 40°^(/) C. 75% RH Tests(Acceptance Criteria) 0 1 month Appearance Clear solution Clear solutionAssay (Release) ² 98.6 100.0 (95.0-105.0% Label Strength) (98.9, 98.3,98.7) (101.2, 99.5, 99.4) Assay (Shelf-life) ² (90.0-105.0% LabelStrength) Individual Degradants (Bupivacaine N-oxide ≤ 2.0%, all otherindividuals ≤ 0.2% by Area Normalization) 1) Bupivacaine N-oxide 0.1 0.22) 2,6-Dimethylaniline n.d. n.d. Total Degradation Products³ (≤3.0% byArea normalization) 0.1 0.2 Drug Release (Criteria) % Cumulative ReleaseAverage (Range)  1 hr (0-10% of target) 6 (6-7) 5 (5-7)  4 hr Reportvalue 18 (17-18) 16 (16-17)  8 hr Report value 27 (26-28) 25 (25-26) 12hr Report value 36 (34-37) 34 (33-34) 18 hr (40-70% of target) 54(49-58). 55 (53-58) 24 hr Report value 66 (64-69) 63 (62-65) 36 hrReport value 84 (81-87) 82 (80-83) 48 hr Report value 90 (87-93) 87(85-88) 72 hr (75-105% of target) 92 (88-97) 90 (88-91) Degree ofColoration (Record results) BY4 BY2 Volume in Container ⁴ (NLT 7.5 mL)6.1-6.2 Test not performed Bacteria toxins (≤25 EV/mL); Test notperformed Test not performed Particular Matter, Microscopy (≥10 μm:≤3000 particles/vial) 3, 5 46 (≥25 μm: ≤3000 particles/vial) 1, 2 17Sterility (meets USP/EP) Test not performed Test not performed¹Duplicate testing in particular matter were performed and individualvalues are reported ² Average and individual assay values are reported.³The total degradation products are based on the sum of all individualdegradants at or greater than 0.1%. Average values are reported. ⁴ Rangeof values is reported from 10 vials.

Example 3

Formulation A was filled into glass vials under a nitrogen atmosphere.The oxygen content of the headspace in the vials was tested.

The data was collected on a Lighthouse Instruments Headspace OxygenAnalyzer Model FMS-760. A summary of the data is presented in the belowTable 3.1, which shows the average, standard deviation, and % RSD foreach lot (in wt % oxygen). BOR is Beginning of Run, MOR is Middle ofRun, and EOR is End of Run indicating when vials were pulled foranalysis during the filling run.

TABLE 3.1 Oxygen Headspace Oxygen Headspace Results (%) Results (%) LotBOR MOR EOR Lot BOR MOR EOR 1 7.2 6.8 6.9 2 5.8 7.7 8.6 5.1 6.7 6.2 7.58.0 7.7 5.5 6.9 6.6 7.6 7.8 7.0 6.5 6.4 6.3 6.4 7.1 6.5 6.4 6.6 7.3 7.69.4 7.2 5.8 7.1 7.5 7.8 7.4 7.3 6.3 6.3 6.0 7.7 7.4 7.9 5.9 7.1 6.3 6.88.3 9.5 6.0 7.0 8.5 6.2 8.2 8.9 6.2 6.6 6.9 7.7 7.4 8.3 6.4 7.0 6.7 6.37.1 8.7 5.8 6.4 6.5 6.6 7.5 8.2 5.6 6.4 7.4 7.6 7.3 8.3 6.6 6.6 6.6 7.48.5 8.6 6.0 7.1 7.1 7.6 7.0 7.4 Average 6.1 6.7 6.9 Average 7.1 7.7 8.0SD 0.5 0.3 0.6 SD 0.7 0.6 0.8 % RSD 8.4 4.3 9.3 % RSD 9.5 8.4 10.2 GrandAve 6.6 Grand Ave 7.6 Grand SD 0.6 Grand SD 0.8 Grand % RSD 9.1 Grand %RSD 10.5

Example 4

A study was conducted to determine the Appearance, Degree of Colorationof Liquids, Assay, and Degradation Products, including2,6-Dimethylaniline, formed in Formulation A after exposure toaccelerated light per ICH Q1B Guidance for Industry: “PhotostabilityTesting of New Drug Substances and Products”.

Experimental

Option 2 of the ICH Q1B guidance was followed for the accelerated lightconditions. Option 2 states that the same sample should be exposed toboth the cool white fluorescent and near ultraviolet lamp. The sourcesof controlled light were: a cool white fluorescent lamp designed toproduce an output similar to that specified in ISO 10977 (1993); and anear UV fluorescent lamp having a spectral distribution from 320 nm to400 nm with a maximum energy emission between 350 nm and 370 nm; asignificant proportion of UV should be in both bands of 320 to 360 nmand 360 to 400 nm. Samples were exposed to light providing an overallillumination of not less than 1.2 million lux hours and an integratednear ultraviolet energy of not less than 200 watt hours/square meter.Three sets of samples, each placed alongside each other, from each lotwere exposed to the accelerated light conditions of:

-   -   1) Unprotected vials, were directly illuminated.    -   2) Protected vials, were wrapped in aluminum foil. These were        used as dark controls to evaluate the contribution of thermally        induced change to the total observed change.    -   3) Protected vials, were in secondary containers or cartons.        These cartons hold 10 vials (in a 2×5 configuration, with a        plastic divider separating the two rows) and are composed of        white clay coated chipboard of approximate dimensions        2.25×2.25×5.625 inches with a thickness of 0.020 inches. These        cartons are from Royal Paper Box Company, Montebello, Calif.,        who sourced the chipboard material from Clearwater Paper        Corporation, Spokane, Wash. using their Candesce CIS stock.

The samples were placed horizontally with respect to the light source.

Stability Results

Tables 4.1 and 4.2 show the photostability results for two differentlots of Formulation A. The data in Tables 4.1 and 4.2 show that theamount of 2,6-dimethylaniline ranged from 36.1 to 54.1 ppm in theunprotected vials, far exceeding the specification limit of 10 ppm. Thealuminum foil wrapped vials had 2,6-dimethylaniline ranging from 0.4 to0.6 ppm. The protected vials in cartons had 2,6-dimethylaniline rangingfrom 1.4 to 1.7 ppm.

The bupivacaine N-oxide degradation product increased to 0.2% in theunprotected vials, but remained below quantitation limit in the aluminumfoil wrapped and carton stored vials.

The average bupivacaine assay values were 1.0 to 1.20 higher in thevials stored in the cartons compared to the unprotected vials.

The results in Tables 4.1 and 4.2 show that a carton can sufficientlyprotect Formulation A from light induced degradation so the drug productremains within specifications.

TABLE 4.1 Photostability Data for Formulation A, Lot #4.1 Appearance,Degree of Coloration of Liquids, Assay, Degradation Products, and2,6-Dimethylaniline Test Results Exposed to Accelerated Light (1,218,060Lux hrs; 232 W hrs/m²) Protected-Stored in Test AcceptanceProtected-Wrapped in Secondary Packaging- Attributes Method Criteria¹Un-protected Aluminum Foil Unit Dose Carton Appearance Visual Clearlight yellow Clear light yellow liquid; Clear yellow brown Clear yellowbrown to brown liquid; essentially free of liquid; essentially liquid;essentially free essentially free of particulate matter free ofparticulate of particulate matter particulate matter matter Degree ofColoration of EP-2.2.2 ≤6x BY1 BY4 (with yellow tint) BY3 BY3 LiquidsBY4 (with yellow tint) BY3 BY3 Assay HPLC with UV 90.0-105.0% 97.2(97.1. 97.2) 97.8 (97.7, 97.9) 98.4 (98.6, 98.2) detector DegradationProducts Bupivacaine N-oxide HPLC with UV ≤1.0% 0.1 (0.1. 0.1) BQL (BQL,BQL) BQL (BQL, BQL) Individual Unspecified detector ≤0.2% RRT = 0.79; NDND Degradants BQL (BQL, BQL) Total Degradation ≤2.0% 0.1 (0.1, 0.1) <0.1(<0.1, <0.1) <0.1 (<0.1, <0.1) Products Benzyl Acetate ≤20 mg/mL 3.4(3.4, 3.4) 3.4 (3.4, 3.4) 3.4 (3.4. 3.4) Benzyl Isobutyrate ≤10 mg/mL1.4 (1.4, 1.4) 1.4 (1.4, 1.4) 1.5 (1.5, 1.4) 2,6-Dimethylaniline HPLCwith ≤10 ppm 37.1 (36.1, 38.1) 0.6 (0.5, 0.6) 1.7 (1.7, 1.7)Electrochemical detector ¹Acceptance criteria were changed during thedevelopment.

TABLE 4.2 Photostability Data for Formulation A, Lot #4.2 Appearance,Degree of Coloration of Liquids, Assay, Degradation Products, and2,6-Dimethylaniline Test Results Exposed to Accelerated Light (1,218,060Lux hrs; 232 W hrs/m²) Protected-Stored in Test AcceptanceProtected-Wrapped in Secondary Packaging- Attributes Method CriteriaUn-protected Aluminum Foil Unit Dose Carton Appearance Visual Clearlight yellow Clear light yellow Clear yellow Clear yellow brown to brownliquid; liquid; essentially brown liquid; liquid; essentially free ofessentially free of free of particulate essentially free of particulatematter particulate matter matter particulate matter Degree of Colorationof EP-2.2.2 ≤6x BY1 BY4 (with yellow tint) BY3 BY3 Liquids BY4 (withyellow tint) BY3 BY3 Assay HPLC with 90.0-105.0% 98.7 (98.7, 98.7) 99.9(100.0, 99.7) 99.7 (99.5, 99.8) UV detector Degradation ProductsBupivacaine N-oxide HPLC with ≤1.0% 0.2 (0.2, 0.2) BQL (BQL, BQL) BQL(BQL, BQL) Individual Unspecified UV detector ≤02% RRT = 0.57; RRT =0.57; RRT = 0.57; Degradants . BQL (BQL, BQL) BQL (BQL. BQL) BQL (BQL,BQL) RRT = 0.79; BQL (BQL, BQL) Total Degradation ≤2.0% 0.2 (0.2, 0.2)<0.1 (<0.1, <0.1) <0.1 (<0.1, <0.1) Products Benzyl Acetate ≤20 mg/mL4.1 (4.1, 4.1) 4.1 (4.1, 4.0) 4.1 (4.1, 4.1) Benzyl Isobutyrate ≤10mg/mL 1.6 (1.6, 1.6) 1.7 (1.7, 1.7) 1.7 (1.6, 1.7) 2,6-DimethylanilineHPLC with ≤10 ppm 53.6 (54.1. 53.1) 0.4 (0.4, 0.4) 1.5 (1.4. 1.5)Electrochemical Detector

Formulation A should be protected from light, since photostabilitytesting according to ICH Q1B has shown an increase of2,6-dimethylaniline. The product is packaged in cartons to provideprotection from light.

Example 5

Formulation A was tested for 2,6-dimethylaniline by electrochemicaldetection. For analysis, an aliquot of formulation was diluted 250 timeswith an aqueous buffer/methanol/acetonitrile diluent. Aftersolubilization of the sample, a small aliquot is transferred into anHPLC vial for analysis using an electrochemical detector.

A series of experiments was conducted examining the effects of amber andred colored glassware on the stability of the 2,6-dimethylaninilinereference standard, using electrochemical detection, at a concentrationof 3 ng/mL in an aqueous buffer/methanol solution.

In Experiment 1, the 2,6-dimethylaniline was prepared at a concentrationof 3 ng/mL in a clear, colorless glass 100 mL volumetric flask. Aliquotswere transferred into clear HPLC glass vials, and assayed againstexternal standards. The 3 injections of the 2,6-dimethylaniline wereconsistently near 3 ng/mL.

In Experiment 2, the 2,6-dimethylaniline solution at 3 ng/mL prepared ina clear, colorless glass 100 mL volumetric flask was transferred toamber HPLC vials. The 4 samples injected from the amber glass HPLC vialshad a 2,6-dimethylaniline content approximately 8 to 12 times higherthan the results in Experiment 1.

In Experiment 3, the 2,6-dimethylaniline was prepared at a concentrationof 3 ng/mL in a red colored glass 100 mL volumetric flask that had aRAY-SORB® coating to protect from light. An aliquot was transferred intoa clear HPLC glass vial, and assayed against external standards. Thesample injection had the same 2,6-dimethylaniline concentration value asthat in Experiment 1.

In Experiment 4, the 2,6-dimethylaniline solution at 3 ng/mL prepared inthe red colored glass 100 mL volumetric flask coated with RAY-SORB® wastransferred to an amber HPLC vial. The injected sample from the amberglass HPLC vial had a 2,6-dimethylaniline content approximately 5 timeshigher than the results in Experiment 1 and Experiment 3.

The conclusion from these experiments is that there is some componentfrom the amber glass HPLC vials that reacts with 2,6-dimethylaniline,creating higher concentrations of 2,6-dimethylaniline, than when the2,6-dimethylaniline solution is stored in clear glass HPLC vials.

TABLE 5.1 Concentration of 2,6-Dimethlylaniline Standard Stored inDifferent Color Glassware Color of Observed Concentration ExperimentVolumetric Color of of Standard Number Flask HPLC Vial (ng/mL) 1 Clear¹Clear² 3.0, 3.0, 3.1 2 Clear¹ Amber³ 24.5, 28.4, 34.6, 38.1 3 Red⁴Clear²  3.0 4 Red⁴ Amber³ 14.9 ¹Clear, colorless, Kimble Glassvolumetric flasks catalog 28014, are manufactured from “33 expansion”,low extractables borosilicate glass, conforming to USP Type 1 and ASTME438, Type 1, Class A requirements. ²Clear, colorless HPLC vials arefrom Thermo Fisher Scientific, catalog C40115W. ³Amber HPLC vials arefrom Agilent Technologies, Part Number: 5182-0545. Amber HPLC vials aremanufactured by the addition of metal oxides to clear colorless glass.See Table 5.2 for typical composition of amber and clear glass. ⁴Redcolored, Kimble Glass volumetric flasks, catalog 28016, are manufacturedfrom “33 expansion”, low extractables borosilicate glass, conforming toUSP Type 1 and ASTM E438, Type 1, Class A requirements, and thenRAY-SORB ® processed, which is a proprietary technology providing aconsistent, durable, and uniform coating for light protection.

Table 5.2 lists the typical composition of clear and amber glass HPLCvials from Waters Corporation. The use of metal oxides, especially ironoxide and titanium oxide, imparts the amber color to the glass. Thepresence of these metals in amber glass HPLC vials is the probablereason for the analytically measured amounts of 2,6-dimethylanilinebeing significantly higher in amber HPLC vials compared to clear,colorless vials (Experiments 2 and 4, in Table 5.1). The results of thisexperiment suggest that the best way to protect the product from light(to reduce the impurities/degradants) is to fill the formulation intoclear vials packaged in boxes or cartons rather than to fill theformulation into amber glass vials.

TABLE 5.2 Chemical Composition (main components in approx. wt %) Type ofGlass SiO₂ B₂O₃ Al₂O₃ TiO₂ Fe₂O₃ Na₂O K₂O BaO CaO Amber “51 69 10 6 3 16 2 2 0.5 expansion” Clear “33 80 11 7 7 2 <0.1 0.5 expansion”

Example 6 Summary

The purpose of this study was to evaluate the compatibility ofFormulation A with three different types of coated serum 20 mm, 4432/50gray chlorobutyl rubber stoppers from West Pharmaceutical Services(West). The results of this study support the selection of the stopperthat has FluroTec® coated on the top and bottom surfaces, West partnumber 19700038 (Drawing No. WS-792).

Background

Formulation A was filled into vials that were stoppered with 20 mm,Teflon faced, 4432/50 gray chlorobutyl rubber serum stoppers from West(part number 10144806) as part of the primary closure system. The Teflonface was in contact with the formulation. The manufacturing process wason a small scale, and the stoppers were manually inserted into the vialsand crimped sealed. This stopper would need to be siliconized to allowfor its use in high speed filling lines at a commercial facility becausethe top and edges of the stopper are not lubricated. The standardsiliconization process for stoppers can introduce extractable siliconeoil into the finished product, since silicone oil is readily soluble inFormulation A. Therefore, three other kinds of chemically resistantstoppers from West were evaluated that would be more appropriate for useat a commercial facility and would not require siliconization since theyhave various coatings on both the top and bottom surfaces.

The first serum stopper selected for study was coated with FluroTec onboth surfaces, West part number 19700038 (20 mm, 4432/50 graychlorobutyl rubber; Drawing No. WS-792). The FluroTec film was appliedduring the molding process of the stopper to the top (flange) and to thebottom (plug) surfaces of the stopper. FluroTec film provides aneffective barrier against organic and inorganic stopper extractables tominimize interactions between the drug formulation and closure. Theproprietary fluorocarbon film, made from a modifiedethylene-tetrafluoroethylenene (ETFE) copolymer, also reduces thesorption of the drug product. In addition, the low surface energy of theFluroTec film provides sufficient lubricity, such that siliconization ofthe stopper is not needed, thus eliminating a potential source ofcontamination.

The second and third kinds of serum stoppers used in this study hadanother type of coating available from West, called B2-coating. TheB2-coating is a cross-linkable high molecular weightpolydimethylsiloxane coating that is applied to the surface of rubberstoppers. The B2-coating process minimizes the transfer of silicone oilinto drug solutions. It also eliminates the need for conventionalsiliconization to facilitate manufacturing of the product. The B2 coatedstoppers evaluated in this study only had the top surfaces coated to themaximum level (level 4), while the bottom surfaces were not coated(level 0). The West nomenclature used to describe the kind of coatingapplied to the stoppers in this study is B2-40. This B2-40 coating wasapplied to stoppers that had either a Teflon or a FluroTec coating onthe bottom (plug) face. The Teflon and FluroTec coatings are similar,but not identical fluorinated copolymers. The stopper with B2-40 on thetop with Teflon on the bottom is West part number 10144942 (20 mm,4432/50 gray chlorobutyl rubber, Drawing No. WS-577), and the stopperwith B2-40 on the top with FluroTec on the bottom is West part number19700022 (20 mm, 4432/50 gray chlorobutyl rubber, Drawing No. WS-791).Although the amount of extractable silicone oil was significantlyreduced with the B2 process, there were still measurable extractables.Because the stoppers were washed and sterilized in bulk, the B2-40coating on the top of stoppers are randomly in contact with the bottomof other stoppers. Therefore there was the potential for silicone oiltransfer onto the FluroTec and Teflon plug faces of these B2-40 coatedstoppers, and thus transfer into the product.

Experimental Methods

Formulation Composition and Container/Closure System

Formulation A was prepared with bupivacaine base at 12% w/w, SAIB at 66%w/w, and benzyl alcohol at 22% w/w. The lot was filtered and filled (˜8mL each) into approximately 600 Type 1 10 mL glass vials (manufacturedby Schott for West, part number 68000320.

About 200 vials were stoppered with each of the three different kinds of20 mm stoppers from West. Table 6.1 summarizes the lot information foreach set of packaged product. Aluminum crimp seals (West part number54202059, DURECT code 3094, lots G0050 and G0106) were used to seal theproduct. To simulate the anticipated aseptic manufacturing process, thefilled, stoppered vials were not terminally sterilized by gammairradiation.

TABLE 6.1 Formulation A Packaged Lot and Packaging InformationFormulation Description of the Coated A Lot Stoppers for Each Lot WestDrawing Number Top (Flange)/Bottom (Plug) Part No. Lot No. No. 6.1FluroTec/FluroTec 19700038 J4204R WS-792 6.2 B2-40/Teflon 10144942J5151B WS-577 6.3 B2-40/FluroTec 19700022 J6116 WS-791

Stability Procedure

Ninety three (93) product filled vials of each kind of stopper werelabeled and packaged in secondary containers (corrugated cartons), andplaced on stability in the inverted position at 25° C./60% RH and 40°C./75% RH.

The analytical tests for the stability studies included appearance,identity, potency and related substances/degradation products. Theidentity test was performed at the initial time point only.

At the initial time point, two vials were used for assay and degradantstesting instead of three vials. This did not impact the quality of thedata in this study.

Although the study was set up with the intention to conduct testing upto 12 months at 25° C./60% RH, the study was stopped after analysis ofthe 6 months stability samples. The stability data for up to 6 months atboth 25° C./60% RH and 40° C./75% RH were deemed sufficient to drawconclusions about the compatibility of Formulation A with the threedifferent stoppers.

Visual appearance testing was only performed at initial and 1 month, andparticulate matter testing (USP <788>) was only performed at 1 and 3months. The practice during preparation of assay samples was to visuallyconfirm a clear solution, free of particulates. These observations werenot documented since they were as expected.

A visual color assessment test using EP 2.2.2 color standards of thebrown yellow (BY series, 2 mL ampoules from Fluka, part number 83952)was added at initial and at 1 month (25° C./60% RH and at 40° C./75%RH). This test was discontinued after 1 month since the sample color wasdarker than BY1, which is the darkest in the set. The test was conductedby one analyst with confirmation of the visual color assessment by asecond analyst. To conduct the test, 1 mL of formulation was transferredinto a clear 1.8 mL HPLC glass vial and it was measured under ambientlaboratory light against commercial color standards in 2 mL glassampoules. The inner diameter, or light pathlength, of the 2 mL ampoules(9.53 mm) for the standards was essentially the same as that of the 1.8mL glass vials (10.03 mm) used for the samples.

Results and Discussion

Tables 6.2 and 6.3 list the results for the three different types ofstopper. Testing included visual appearance, solution color by EP 2.2.2(brown yellow, BY series), assay and degradants by HPLC, and particulatematter by microscopy (USP <788>). For ease of comparison of the stopperdata, Table 6.4 summarizes the average % LS bupivacaine, the % remainingbupivacaine relative to the initial values, the % bupivacaine N-oxideand the total % degradants.

TABLE 6.2 Stability Data at 25° C./60% RH for Stoppers with FormulationA Stopper Top/Bottom 25° C./60% RH Attribute Method Coatings Initial 1Month 3 Months 6 Months Appearance¹ Visual FluroTec / Clear light yellowliquid. Clear brown yellow not determined not determined (EP 2.2.2)FluroTec (Darker than BY5) liquid not determined not determined (BY3)B2-40/ Clear light yellow liquid. Clear brown yellow not determined notdetermined Teflon (Darker than BY5) liquid not determined not determined(BY3) B2-40/ Clear light yellow liquid, Clear brown yellow notdetermined not determined FluroTec (Darker than BY5) liquid notdetermined not determined (BY3) Identity HPLC All Stoppers Bupivacaineis present not determined not determined not determined Assay HPLCFluroTec/ 100.9% LS 100.5% LS 99.5% LS 102.2% LS FluroTec (101.5, 100.2)(100.4, 100.7, 100.4) (99.9, 98.9, 99.7) (101.6, 102.4, 102.7) B2-40/99.8% LS 99.8% LS 98.3% LS 100.2% LS Teflon (99.7, 99.8) (100.3, 99.5,99.5) (99.2, 98.1, 97.5) (100.2, 100.2, 100.2) B2-40/ 101.5% LS 99.3% LS99.4% LS 100.3% LS FluroTec (101.5, 101.4) (99.4, 99.4, 99.1) (99.7,98.5, 99.9) (100.5, 100.3, 100.1) Degradation HPLC FluroTec/ %Bupivacaine N-oxide % Bupivacaine N-oxide % Bupivacaine N-oxide %Bupivacaine N-oxide Products FluroTec 0.2% (0.2%, 0.2%) 0.1% (0.1%,0.1%, 0.1%) 0.2% (0.2%, 0.2%, 0.2%) 0.2%(0.2%, 0.2%, 0.2%) Unknown RRT =0.24 Unknown RRT = 0.24 Unknown RRT = 0.28 Unknown RRT = 0.28 0.05-0.06%0.04-0.04% 0.04-0.05% 0.05-0.05% B2-40/ % Bupivacaine N-oxide %Bupivacaine N-oxide % Bupivacaine N-oxide % Bupivacaine N-oxide Teflon0.1% (0.1%, 0.2%) 0.1% (0.1%, 0.1%, 0.1%) 0.2% (0.2%, 0.2%, 0.2%) 0.2%(0.2%, 0.2%, 0.2%) Unknown RRT = 0.24 Unknown RRT = 0.24 Unknown RRT =0.28 Unknown RRT = 0.28 0.04-0.06% 0.04-0.04% 0.04-0.04% 0.05-0.05%B2-40/ % Bupivacaine N-oxide % Bupivacaine N-oxide % Bupivacaine N-oxide% Bupivacaine N-oxide FluroTec 0.1% (0.1%, 0.1%) 0.1% (0.1%, 0.1%, 0.1%)0.2% (0.2%, 0.2%, 0.2%) 0.2% (0.2%, 0.2%, 0.2%) Unknown RRT = 0.24Unknown RRT = 0.24 Unknown RRT = 0.28 Unknown RRT 0.28 0.04-0.04%0.04-0.05% 0.05-0.05% 0.05-0.05% Particulate USP FluroTec/ NotDetermined Not Determined ≥10 μm particles/vial: 30 ≥10 μmparticles/vial: 18 Matter <788> FluroTec ≥25 μm particles/vial: 3 ≥25 μmparticles/vial: <10² B2-40/ Not Determined Not Determined ≥10 μmparticles/vial: 57 ≥10 μm particles/vial: 42 Teflon ≥25 μmparticles/vial: 3 ≥25 μm particles/vial: 3 B2-40/ Not Determined NotDetermined ≥10 μm particles/vial: 45 ≥10 μm particles/vial: 42 FluroTec≥25 μm particles/vial: <10² ≥25 μm particles/vial: 9 ¹Clear liquid, freeof particulate matter, yellow to brown. In addition to the visualappearance test, a visual color assessment using EP color standards ofthe BY series was also performed and verified by a second analyst. Thecolor result is for information only. ²A value of <10 indicates that noparticles were detected.

TABLE 6.3 Stability Data at 40° C./75% RH for Stoppers with FormulationA Stopper Coatings Top/ 40° C./75% RH % Attributes Method Bottom Initial1 Month 3 Months 6 Months Appearance¹ Visual FluroTec/ Clear light Clearbrown not determined not determined (EP 2.2.2) FluroTec yellow liquid.yellow liquid not determined not determined (Darker than BY5) (BY2)B2-40/ Clear light Clear brown not determined not determined Teflonyellow liquid. yellow liquid not determined not determined (Darker thanBY5) (BY2) B2-40/ Clear light Clear brown not determined not determinedFluroTec yellow liquid. yellow liquid not determined not determined(Darker than BY5) (BY2) Assay HPLC FluroTec/ 100.9% LS 98.0% LS 99.2% LS100.9% LS FluroTec (101.5, 100.2) (100.3, 99.6, 92.6², (99.6, 98.8,99.2) (100.6, 100.4, 101.6) 98.1², 98.0, 99.2)² B2-40/ 99.8% LS 99.1% LS99.0% LS 100.6% LS Teflon (99.7, 99.8) (99.9, 98.5, 98.9) (98.9, 97.9,100.2) (99.7, 100.9, 101.1) B2-40/ 101.5% LS 99.1% LS 98.2% LS 100.7% LSFluroTec (101.5, 101.4) (99.0, 99.1, 99.3) (98.1, 98.1, 98.4) (100.3,101.3, 100.6) Degradation HPLC FluroTec/ % Bupivacaine N-oxide %Bupivacaine N-oxide % Bupivacaine N-oxide % Bupivacaine N-oxide ProductsFluroTec 0.2% (0.2%, 0.2%) 0.1% (0.1%, 0.1%, 0.1%) 0.3% (0.3%, 0.3%,0.2%) 0.3%(0.3%, 0.3%, 0.3%) Unknown RRT = 0.24 Unknown RRT = 0.24Unknown RRT = 0.28 Unknown RRT = 0.28, 0.05-0.06% 0.04-0.04% 0.04-0.05%RRT = 0.30 0.05-0.05%; 0.01-0.02% B2-40/ % Bupivacaine N-oxide %Bupivacaine N-oxide % Bupivacaine N-oxide % Bupivacaine N-oxide Teflon0.1% (0.1%, 0.2%) 0.1% (0.1%, 0.1%, 0.1%) 0.3% (0.3%, 0.3%, 0.3%) 0.3%(0.3%, 0.3%, 0.3%) Unknown RRT = 0.24 Unknown RRT = 0.24 Unknown RRT =0.28 Unknown RRT = 0.28, 0.04-0.06% 0.04-0.04% 0.04-0.05% RRT = 0.300.05-0.05%; 0.02-0.02% B2-40/ % Bupivacaine N-oxide % BupivacaineN-oxide % Bupivacaine N-oxide % Bupivacaine N-oxide FluroTec 0.1% (0.1%,0.1%) 0.1% (0.1%, 0.1%, 0.1%) 0.3% (0.3%, 0.3%, 0.3%) 0.3% (0.3%, 0.3%,0.3%) Unknown RRT = 0.24 Unknown RRT = 0.24 Unknown RRT = 0.28 UnknownRRT = 0.28, 0.04-0.04% 0.04-0.05% 0.05-0.05% RRT = 0.30 0.04-0.05%;0.01-0.02% Particulate USP FluroTec/ Not Determined ≥10 μmparticles/vial: 10 >10 μm particles/vial: 48 ≥10 μm particles/vial: 18Matter <788> FluroTec ≥25 μm particles/vial: <50 ≥25 μm particles/vial:<10³ ≥25 μm particles/vial: <10 B2-40/ Not Determined ≥10 μmparticles/vial: 10 ≥10 μm particles/vial: 45 ≥10 μm particles/vial: 36Teflon ≥25 μm particles/vial: <50 ≥25 μm particles/vial: 3 ≥25 μmparticles/vial: <10 B2-40/ Not Determined ≥10 μm particles/vial: 25 ≥10μm particles/vial: 39 ≥10 μm particles/vial: 93 FluroTec ≥25 μmparticles/vial: <50 ≥25 μm particles/vial: <10 ≥25 μm particles/vial: 3¹Clear liquid, free of particulate matter, yellow to brown. In additionto the visual appearance test, a visual color assessment using EP colorstandards of the BY series was also performed and verified by a secondanalyst. The color result is for information only. ²The initial valuefrom vial #3 was 92.6%. Because of this out of trend result, anothersample was prepared from the same vial, giving a value of 98.1%. Duringthe retest of vial #3, two new vials were sampled and tested. Thus atotal of five vials were tested, of which two samples came from vialfive vials are reported, and the resulting average was 98.0%. ³A valueof <10 indicates that no particles were detected.

TABLE 6.4 Chemical Compatibility of Formulation A Packaged with ThreeDifferent Types of Stoppers at 25° C./60% RH and 40° C./75% RH for up to6 Months Stopper Coatings Top/Bottom FluroTec/FluroTec B2-40/TeflonB2-40/FluroTec Storage % % % % Total % % % % Total % % % % TotalConditions Month LS Remaining N-oxide Degradants LS Remaining N-oxideDegradants LS Remaining N-oxide Degradants Initial 0 100.9 100.0 0.2 0.299.8 100.0 0.1 0.1 101.5 100.0 0.1 0.1 25° C./60% RH 1 100.5 99.6 0.10.1 99.8 100.0 0.1 0.1 99.3 97.8 0.1 0.1 3 99.5 98.6 0.2 0.2 98.3 98.50.2 0.2 99.4 97.9 0.2 0.2 6 102.2 101.3 0.2 0.2 100.2 100.4 0.2 0.2100.3 98.8 0.2 0.2 40° C./75% RH 1 98.0 97.1 0.1 0.1 99.1 99.3 0.1 0.199.1 97.6 0.1 0.1 3 99.2 98.3 0.3 0.3 99.0 99.2 0.3 0.3 98.2 96.7 0.30.3 6 100.9 100.0 0.3 0.3 100.6 100.8 0.3 0.3 100.7 99.2 0.3 0.3

Appearance and Solution Color

The visual appearance of all the samples with different types ofstoppers were “clear light yellow liquid” at initial, “clear brownyellow liquid” at 1 month for 25° C./60% RH, and “clear brown yellowliquid” at 1 month for 40° C./75% RH. Using EP 2.2.2 BY color standards(color increases from BY7 to BY1), all the samples at initial weredarker than BY5, at 1 month at 25° C./60% RH they were BY3, and at 1month at 40° C./75% RH they were BY2. The product's color increased as afunction of storage temperature and time. The different types ofstoppers did not affect the visual appearance of product.

Particulate Matter

Particulate matter was tested by the microscopic method (USP<788>), andthe data were similar among the three types of stoppers at 25° C./60% RHfor 3 and 6 months (Table 6.2), and at 40° C./75% RH for 1, 3 and 6months (Table 6.3). The data were significantly below the small volumeparenteral specifications of: ≥10 μm: ≤3000 particles/vial and ≥25 μm:≤300 particles/vial.

Assay and Degradants

The % LS bupivacaine data was similar for each of the type of stoppersafter 6 months at both 25° C./60% RH and 40° C./75% RH. BupivacaineN-oxide (the major product degradant) exhibited similar minor increasesover time at 25° C./60% RH and 40° C./75% RH for each of the stoppers.The unknown degradant profiles at RRT 0.24, 0.28, and 0.30 was the samefor all three types of stoppers through 6 months at 25° C./60% RH and40° C./75% RH.

A review of the data summarized in Table 6.4 indicates that there are noformulation stability differences between the stoppers.

Conclusions

In conclusion, the three stoppers had similar physical and chemicalperformances with Formulation A. Although the B2-40 process is a way ofapplying a more controlled, less amount of silicone than conventionalsiliconization, the potential still exists for some extractable siliconeto be solubilized in the formulation due to the presence of benzylalcohol. Therefore, the recommendation is to pursue theFluroTec/FluroTec stopper, since this will avoid the use of any type ofsilicone, including B2.

Example 7

Sucrose acetate isobutyrate was tested for metal content as follows. Thesample was prepared with a 0.1 g weighed portion mixed with 2 mL nitricacid and 0.5 mL hydrochloric acid for 1 hour on a block digestor set at110° C. After cooling, 0.5 mL of 30% hydrogen peroxide was added, andthe digestion resumed for 30 minutes (the material appeared dissolved).After cooling, internal standard solution was added and dilution withpurified water to 20 g produced a solution for ICP-MS analysis.

The results are shown below:

Detection Element ppm Limit Aluminum ND 0.8 Antimony ND 0.02 Arsenic ND0.02 Barium ND 0.02 Beryllium ND 0.02 Bismuth ND 0.02 Boron ND 0.5Bromine ND 2 Cadmium ND 0.02 Calcium ND 40 Cerium ND 0.02 Cesium ND 0.02Chromium ND 0.2 Cobalt ND 0.8 Copper ND 0.3 Dysprosium ND 0.02 Erbium ND0.02 Europium ND 0.02 Gadolinium ND 0.02 Gallium ND 0.02 Germanium ND0.02 Gold 0.4 0.02 Hafnium ND 0.02 Holmium ND 0.02 Iodine ND 0.05Iridium ND 0.05 Iron 2   1 Lanthanum ND 0.02 Lead ND 0.02 Lithium ND0.02 Lutetium ND 0.1 Magnesium ND 1 Manganese ND 0.04 Mercury ND 0.1Molybdenum ND 0.02 Neodymium ND 0.02 Nickel ND 0.02 Niobium ND 0.02Osmium ND 0.08 Palladium ND 0.06 Phosphorus ND 2 Platinum ND 0.02Potassium ND 5 Praseodymium ND 0.02 Rhenium ND 0.02 Rhodium ND 0.02Rubidium ND 0.02 Ruthenium ND 0.03 Samarium ND 0.02 Selenium ND 0.1Silver ND 0.02 Sodium ND 8 Strontium ND 0.08 Tantalum ND 0.02 TelluriumND 0.02 Thallium ND 0.2 Thorium ND 0.03 Thulium ND 0.02 Tin  0.06 0.04Titanium ND 0.2 Tungsten ND 0.02 Uranium ND 0.02 Vanadium ND 0.06Ytterbium ND 0.02 Yttrium ND 0.04 Zinc ND 0.09 Zirconium ND 0.02

Formulation A was compounded using steel compounding tanks. Siliconetubing was used to transfer Formulation A. Formulation A was filled intoglass vials, which were then sealed with fluorocarbon-coated stoppers.

Formulation A was tested for metal content as follows. The sample wasprepared with a 0.2 g weighed portion mixed with 2 mL nitric acid, 1 mLhydrochloric acid, and 1 mL hydrofluoric acid, then digested in aclosed-vessel microwave system (the material appeared dissolved). Aftercooling, internal standard solution was added and dilution with purifiedwater to 50 g produced a solution for ICP-MS analysis.

The results are shown below:

Detection Element ppm Limit Aluminum ND 0.6 Antimony ND 0.03 Arsenic ND0.07 Barium ND 0.02 Beryllium ND 0.02 Bismuth ND 0.02 Boron ND 0.2Bromine ND 1000 Cadmium ND 0.02 Calcium ND 2 Cerium ND 0.02 Cesium ND0.02 Chromium ND 0.07 Cobalt ND 0.02 Copper ND 0.04 Dysprosium ND 0.02Erbium ND 0.02 Europium ND 0.02 Gadolinium ND 0.02 Gallium ND 0.02Germanium ND 0.02 Gold ND 0.07 Hafnium ND 0.05 Holmium ND 0.02 Iodine ND0.1 Iridium ND 0.02 Iron ND 1 Lanthanum ND 0.02 Lead ND 0.02 Lithium ND0.04 Lutetium ND 0.5 Magnesium ND 1 Manganese ND 0.02 Mercury ND 0.04Molybdenum ND 0.02 Neodymium ND 0.02 Nickel ND 0.02 Niobium ND 0.6Osmium ND 0.2 Palladium ND 0.02 Phosphorus ND 5 Platinum ND 0.02Potassium ND 10 Praseodymium ND 0.02 Rhenium ND 0.02 Rhodium ND 0.02Rubidium ND 0.02 Ruthenium ND 0.02 Samarium ND 0.02 Selenium ND 0.1Silver ND 0.02 Sodium ND 6 Strontium ND 0.02 Tantalum ND 20 Tellurium ND0.02 Thallium ND 0.02 Thorium ND 0.03 Thulium ND 0.02 Tin ND 0.02Titanium ND 0.05 Tungsten ND 0.5 Uranium ND 0.02 Vanadium ND 0.02Ytterbium ND 0.02 Yttrium ND 0.02 Zinc ND 2 Zirconium ND 0.1

Example 8

Formulation A and placebo compositions were evaluated for water content.Formulation A in this study included 12% w/w bupivacaine, 66% w/wsucrose acetate isobutyrate (SAIB), and 22% w/w benzyl alcohol, asdescribed above. Placebo compositions were composed of 75% w/w sucroseacetate isobutyrate (SAIB), and 25% w/w benzyl alcohol.

Filters used during aseptic preparation of Formulation A and placebocompositions can include residual water content resulting incompositions having a detectable amount of water. To ensure that watercontent is minimized or altogether absent from prepared bupivacainecompositions, filters used during aseptic preparation are: 1) tested forintegrity by measuring the bubble point of the filter with pressurizedsterile water for injection; 2) purged with nitrogen for not less than 5minutes at 50 psi to remove any residual water in the filter; and 3)bupivacaine composition (e.g., Formulation A containing 12% w/wbupivacaine or placebo composition) is flushed through the filter withthe filtrate being discarded. In this example, not less than 6 liters ofFormulation A was flushed through the filters before collecting samplecomposition into vials.

The water content in sample vials collected at the beginning, middle andend of the collection process was evaluated. The water content of thecollected sample vials was compared to the water content of bupivacainecomposition in the filtrate flushed through the filters. Historicalwater content from sample vials collected during previous samplepreparation runs was also compared.

Methods Materials

1) Placebo Composition

-   -   Preparation Filter flushes (1 L, 2 L, 3 L, 4 L, 5 L, and 6 L),        and vials from the Beginning, Middle, and End of Run

2) Formulation A—Sample 1

-   -   Preparation Filter flushes (1 L, 2 L, 3 L, 4 L, 5 L, and 6 L),        and vials from the Beginning, Middle, and End of Run

3) Formulation A—Sample 2

-   -   Preparation Filter flushes (1 L, 2 L, 3 L, 4 L, 5 L, 6 L, 7 L, 8        L, 9 L, and 10 L); and vials from the Beginning, Middle, and End        of Run.

4) Vials from Formulation A: A1, B1, C1, D1, E1, F1, G1, and H1, and I1.

5) Vials from placebo composition A

Water Content Testing

Samples were tested according to USP <921>, Method 1c, using an EMScience Aquastar C3000 Coulometric Titrator. Due to the high viscosityof the formulation, the samples required dilution with methanol prior tointroduction into the Coulometric Titrator. Approximately 0.5 g ofFormulation A or placebo composition was accurately weighed into a 10 mLvial. An approximately equal amount of methanol was added and the weightaccurately recorded. If a sample, such as the manufacturing lineflushes, was known to have a high amount of water, then proportionallymore methanol was mixed with the sample. Each vial was then sealed andshaken vigorously for at least 30 seconds.

Approximately 0.5 g of the sample/methanol mixture was delivered intothe Coulometric Titrator by liquid injection. The syringe used todeliver the sample was weighed before and after injection to determinethe amount assayed.

Results Placebo Composition

Table 8.1 summarizes the water content results for the 6 one-literpreparation filter flushes for placebo composition. Each one liter offlush was typically tested in duplicate; with the results being veryconsistent. The first one liter of product flush was essentially allwater. Subsequent flushes steadily reduced the water content toapproximately 0.58% by the 6^(th) liter. Table 8.2 shows the watercontent of the finished placebo composition in vials collected from thebeginning, the middle, and the end of the filling process. Each vial wasassayed in duplicate, with the results being very consistent. Theaverage vial water content results in Table 8.2 were approximately 0.35%for the beginning, 0.19% for the middle, and 0.30% for the end offilling.

TABLE 8.1 Water Content in Preparation Filter Flushes of placebocomposition determined by Karl Fischer Titration % Water Content(Typically Two % Water Content Flush Injections per Flush (Average forFlush Fraction Sample ID Fraction) Fraction) 1^(st) Liter Placebo-1L-196.4341 96.4341 2^(nd) Liter Placebo-2L-1 2.3669 2.3641 Placebo-2L-22.3613 3^(rd) Liter Placebo-3L-1 1.0225 1.0290 Placebo-3L-2 1.03544^(th) Liter Placebo-4L-1 0.8726 0.8825 Placebo-4L-2 0.8924 5^(th) LiterPlacebo-5L-1 0.7625 0.7607 Placebo-5L-2 0.7588 6^(th) Liter Placebo-6L-10.5669 0.5821 Placebo-6L-2 0.5972

TABLE 8.2 Water Content in placebo composition samples by Karl FischerTitration % Water % Water % Water Content Content Content Location of(Two Injections (Vial (Location Vial from Lot Sample ID per Vial)Average) Average) Beginning of Placebo-BOR-1-1 0.2970 0.2918 0.3496 Run(BOR) Placebo-BOR-1-2 0.2866 Placebo-BOR-2-1 0.4125 0.4075Placebo-BOR-2-2 0.4024 Middle of Run Placebo-MOR-1-1 0.1997 0.19260.1906 (MOR) Placebo-MOR-1-2 0.1854 Placebo-MOR-2-1 0.1940 0.1887Placebo-MOR-2-2 0.1833 End of Run Placebo-EOR-1-1 0.4165 0.4103 0.3022(EOR) Placebo-EOR-1-2 0.4040 Placebo-EOR-2-1 0.2037 0.1942Placebo-EOR-2-2 0.1847

Formulation A—Sample 1

Table 8.3 summarizes the water content results for the 6 one-literpreparation filter flushes for Formulation A. Testing was done in thesame manner as for the placebo compositions. The first one liter ofproduct flush was essentially all water. Subsequent flushes steadilyreduced the water content to approximately 1.06% by the 6^(th) liter.Table 8.4 shows the water content of the finished product in vialscollected from the beginning, the middle, and the end of the fillingprocess. The average vial water content results in Table 8.4 wereapproximately 0.35% for the beginning, 0.11% for the middle, and 0.11%for the end of filling.

TABLE 8.3 Water Content in Preparation Filter Flushes of bupivacainecomposition- Sample 1 determined by Karl Fischer Titration % WaterContent (Typically Two % Water Content Flush Injections per (Average forFlush Fraction Sample ID Flush Fraction) Fraction) 1^(st) LiterBupivacaine S1-1L-1 96.9996 96.9996 2^(nd) Liter Bupivacaine S1-2L-12.4935 2.5835 Bupivacaine S1-2L-2 2.6734 3^(rd) Liter BupivacaineS1-3L-1 2.0673 2.0556 Bupivacaine S1-3L-2 2.0438 4^(th) LiterBupivacaine S1-4L-1 1.6314 1.6156 Bupivacaine S1-4L-2 1.5997 5^(th)Liter Bupivacaine S1-5L-1 1.1264 1.1270 Bupivacaine S1-5L-2 1.12756^(th) Liter Bupivacaine S1-6L-1 1.0605 1.0559 Bupivacaine S1-6L-21.0512

TABLE 8.4 Water Content in sustained release bupivacaine compositionsamples- Sample 1 by Karl Fischer Titration % Water Content % Water %Water (Two Content Content Injections (Vial (Location Vial ID Sample IDper Vial) Average) Average) Beginning Bupivacaine S1-BOR-1-1 0.31230.3102 0.3467 of Run Bupivacaine S1-BOR-1-2 0.3080 BupivacaineS1-BOR-2-1 0.3808 0.3833 Bupivacaine S1-BOR-2-2 0.3858 Middle ofBupivacaine S1-MOR-1-1 0.1083 0.1096 0.1119 Run Bupivacaine S1-MOR-1-20.1108 Bupivacaine S1-MOR-2-1 0.1114 0.1143 Bupivacaine S1-MOR-2-20.1171 End of Run Bupivacaine S1-EOR-1-1 0.1105 0.1099 0.1058Bupivacaine S1-EOR-1-2 0.1092 Bupivacaine S1-EOR-2-1 0.1020 0.1018Bupivacaine S1-EOR-2-2 0.1016

Formulation A—Sample 2

The objective of the evaluation was to examine if the water contentbetween the last liter of flush could be more consistent with the valuesobtained in the vials from the beginning of the filling process. ForFormulation A, Sample 2, the nitrogen pressure was increased from 50 to55 psi, and was blown through the filters for not less than 5 minutes.In addition, 10 liters of formulation was flushed through the filtersinstead of 6 liters as in the previous lots.

The water content for these 10 liters of flushes for Formulation A,Sample 2 is shown in Table 8.5. The 1^(st) one liter of flush started atapproximately 2.41% water. This is in contrast to the placebocompositions and Formulation A, Sample 1 (Tables 8.1 and 8.3,respectively) which were greater than 99% water. The increased pressureof the nitrogen purging step of the filters for Sample 2 resulted inless water in the filters prior to flushing the product through it. Thewater content steadily decreased with the number of flushes, with 0.39%water detected in the 10^(th) one-liter flush. Table 8.6 shows that theaverage water content of the finished product in vials collected fromthe beginning, the middle, and the end of the filling process were0.20%, 0.08%, and 0.06%, respectively.

TABLE 8.5 Water Content in Preparation Filter Flushes of placebocomposition- Sample 2 determined by Karl Fischer Titration % WaterContent (Two Injections per % Water Content Flush Flush (Average forFlush Fraction Sample ID Fraction) Fraction) 1^(st) Liter Bupivacaine S21L Flush-1 2.3215 2.4076 Bupivacaine S2 1L Flush-2 2.4936 2^(nd) LiterBupivacaine S2 2L Flush-1 2.0838 2.0499 Bupivacaine S2 2L Flush-2 2.01593^(rd) Liter Bupivacaine S2 3L Flush-1 1.1442 1.1378 Bupivacaine S2 3LFlush-2 1.1313 4^(th) Liter Bupivacaine S2 4L Flush-1 0.7282 0.7327Bupivacaine S2 4L Flush-2 0.7371 5^(th) Liter Bupivacaine S2 5L Flush-10.6185 0.6153 Bupivacaine S2 5L Flush-2 0.6120 6^(th) Liter BupivacaineS2 6L Flush-1 0.5543 0.5528 Bupivacaine S2 6L Flush-2 0.5513 7^(th)Liter Bupivacaine S2 7L Flush-1 0.4848 0.4892 Bupivacaine S2 7L Flush-20.4936 8^(th) Liter Bupivacaine S2 8L Flush-1 0.4748 0.4730 BupivacaineS2 8L Flush-2 0.4712 9^(th) Liter Bupivacaine S2 9L Flush-1 0.34130.3477 Bupivacaine S2 9L Flush-2 0.3541 10^(th) Liter Bupivacaine S2 10LFlush-1 0.3960 0.3949 Bupivacaine S2 10L Flush-2 0.3937

TABLE 8.6 Water Content in Formulation A-Sample 2 determined by KarlFischer Titration % Water Location Content % Water % Water of (TwoContent Content Vial from Injections (Vial (Location the Lot Sample IDper Vial) Average) Average) Beginning Bupivacaine S2 BOR-1-1 0.18400.1840 0.2024 of Run Bupivacaine S2 BOR-1-2 0.1840 Bupivacaine S2BOR-2-1 0.2202 0.2208 Bupivacaine S2 BOR-2-2 0.2214 Middle ofBupivacaine S2 MOR-1-1 0.0841 0.0849 0.0839 Run Bupivacaine S2 MOR-1-20.0857 Bupivacaine S2 MOR-2-1 0.0840 0.0830 Bupivacaine S2 MOR-2-20.0819 End of Bupivacaine S2 EOR-1-1 0.0652 0.0648 0.0640 RunBupivacaine S2 EOR-1-2 0.0643 Bupivacaine S2 EOR-2-1 0.0638 0.0633Bupivacaine S2 EOR-2-2 0.0627

Although the data shows the changes in the preparation process(increased nitrogen pressure and larger volume of product flush) wereeffective in reducing the water content in Formulation A, the resultsfor the filled vials did not appear to be practically different from theprior drying process.

ICH and Prior Clinical Lots of Formulation A

Table 8.7 summarizes the water content results for the 4 ICH lots (eachwith fill sizes of 5 mL and 7.5 mL) and the 2 clinical lots (FormulationA and a placebo) manufactured previously. These lots were manufacturedwith a nitrogen purge of the filters at 50 psi for not less than 5minutes with not less than 6 L flush of product. Two or four vials fromeach lot were tested. The % water content ranged from approximately0.13% to 0.34% for these historical lots that were about 3-4 years oldat the time of testing.

TABLE 8.7 Water Content in Formulation A and placebo compositions byKarl Fischer Titration % Water Content Formulation A Sample (SingleInjection per % Water Content ID ID Vial) (Lot Average) A A-1 0.25030.2366 A-2 0.2229 B B-1 0.1516 0.1478 B-2 0.1439 C C-1 0.1561 0.1632 C-20.1702 D D-1 0.1311 0.1291 D-2 0.1271 E E-1 0.2192 0.2246 E-2 0.2299 FF-1 0.1504 0.1473 F-2 0.1442 G G-1 0.1451 0.1527 G-2 0.1602 H H-1 0.32960.3404 H-2 0.3512 I I-1 0.1344 0.1286 I-2 0.1246 I-3 0.1264 I-4 0.1290Placebo Placebo 0.1600 0.1618 Composition A A-1 Placebo 0.1635 A-2

Conclusions

To reduce or altogether eliminate the water content in Formulation A,the nitrogen purging pressure may be increased from 50 to 55 psi for notless than 5 minutes or until no more water is observed. The total amountof composition flushed through the filters prior to the vial fillingstep is recommended to remain as not less than 6 liters.

Example 9

The degree of coloration at 36 months, 25°/60% RH, for Formulation A,primary and supportive stability lots were compared to the water contentthat were determined at approximately 52 months after the date ofmanufacture, to see if a correlation exists between those twoparameters. In addition, the degree of coloration at 36 months, 25°/60%RH, for a clinical lot of Formulation A was compared to its watercontent determined 34 months after manufacture.

Methods Materials

-   -   1) Formulation A—Primary Stability Samples: PS-A, PS-B, PS-C and        PS-D (5 mL fill)    -   2) Formulation A—Supportive Stability Samples: SS-A, SS-B, SS-C        and SS-D (7.5 mL fill)    -   3) Formulation A—Clinical Samples: CS-A

Water Content Testing

Samples were tested according to USP <921>, Method 1c, using an EMScience Aquastar C3000 Coulometric Titrator. Due to the high viscosityof the formulation, the samples required dilution with methanol prior tointroduction into the Coulometric Titrator. Approximately 0.5 g ofFormulation A was accurately weighed into a 10 mL vial. An approximatelyequal amount of methanol was added and the weight accurately recorded.Each vial was then sealed and shaken vigorously for at least 30 seconds.Approximately 0.5 g of the sample/methanol mixture was delivered intothe Coulometric Titrator by liquid injection. The syringe used todeliver the sample was weighed before and after injection to determinethe amount assayed. Two vials per ICH stability lot were tested forwater content, while four vials from Formulation A clinical samples CS-Awere tested.

Degree of Coloration of Liquids

Samples were tested at the 36 months time point for Formulation Aprimary stability sample compositions, Formulation A supportivestability sample compositions and Formulation A clinical samplecompositions. Color was determined on samples stored both upright andinverted. Formulation A clinical samples CS-A only had vials storedinverted.

Results

Table 9.1 summarizes the Degree of Coloration of Liquid results for thesustained release bupivacaine compositions at the 36 month time point,for samples stored at 25° C./60% RH in the inverted and uprightorientations. The color data for samples CS-A at 36 months, stored onlyin the inverted orientation, is also included. The color results amongthe compositions were similar, with most of the results between 5×BY1and 6×BY1. The color results for Formulation A indicate that theorientation of the vial during storage had no effect on color.Formulation A clinical samples CS-A was described as 6×BY1.

Included in Table 9.1 is the water content of the compositions ofFormulation A, measured approximately 16 months after the colorassessments were done at the 36 months stability time point. The watercontent ranged from approximately 0.13% to 0.34% for the compositions ofFormulation A. In addition, the water content for Formulation A clinicalsamples CS-A was measured approximately 2 months before color wasdetermined at the 36 months time point. Formulation A clinical samplesCS-A had approximately 0.13% water.

FIG. 1 depicts the water content and coloration for each sample in Table9.1. As seen in FIG. 1, at approximately 0.15% water, the color rangedfrom 4×-5×BY1 to 6×BY1; at approximately 0.23% water the color rangedfrom 5×BY1 to 6×BY1; and at approximately 0.34% water the color rangedfrom 5×BY to 5×-6×BY1.

Based on the results depicted in FIG. 1 and summarized in Table 9.1, thecolor of the Formulation A does not darken with an increase of watercontent in the approximate range of 0.13% to 0.34%.

TABLE 9.1 Water Content in Formulation A by Karl Fischer Titration andthe Degree of Coloration of Liquids Data at 36 Months, at 25° C./60% RH,Stored Inverted and Upright Degree of Degree of Coloration at Colorationat 36 Months at 36 Months at 25° C./60% RH, 25° C./60% RH, % WaterStored Inverted, Stored Upright, Content % Water by PR-1562 by PR-1562Fill (Single Content on Other Vials Not on Other Vials Not CompositionSize Sample Injection (Lot Tested for Water Tested for Water ID (mL) IDper Vial) Average) Content Content PS-A 5 PS-A-1 0.2503 0.2366 Between5x-6x BY1, 5x BY1, PS-A-2 0.2229 Between 5x-6x BY1 5x BY1 SS-A 7.5SS-A-1 0.1516 0.1478 Between 4x-5x BY1, 5x BY1, SS-A-2 0.1439 Between5x-6x BY1 5x BY1 PS-B 5 PS-B-1 0.1561 0.1632 5x BY1, 5x BY1, PS-B-20.1702 6x BY1 6x BY1 SS-B 7.5 SS-B-1 0.1311 0.1291 5x BY1, 5x BY1,SS-B-2 0.1271 Between 5x-6x BY1 Between 4x-5x BY1 PS-C 5 PS-C-1 0.21920.2246 Between 5x-6x BY1, 5x BY1, PS-C-2 0.2299 Between 5x-6x BY1 6x BY1SS-C 7.5 SS-C-1 0.1504 0.1473 Between 5x-6x BY1, 5x BY1, SS-C-2 0.1442Between 5x-6x BY1 Between 5x-6x BY1 PS-D 5 PS-D-1 0.1451 0.1527 Between5x-6x BY1, Between 5x-6x BY1, PS-D-2 0.1602 Between 5x-6x BY1 Between5x-6x BY1 SS-D 7.5 SS-D-1 0.3296 0.3404 Between 5x-6x BY1, 5x BY1,SS-D-2 0.3512 Between 5x-6x BY1 5x BY1 CS-A 7.5 CS-A-1 0.1344 0.1286 6xBY1, 6x BY1 Not stored upright CS-A-2 0.1246 CS-A-3 0.1264 CS-A-4 0.1290

Example 10

The effect of peroxide from sucrose acetate isobutyrate or benzylalcohol on Formulation A and placebo compositions was evaluated.Formulation A in this study includes 12% w/w bupivacaine, 66% w/wsucrose acetate isobutyrate (SAIB), and 22% w/w benzyl alcohol, asdescribed above. Placebo compositions were composed of 75% w/w sucroseacetate isobutyrate (SAIB), and 25% w/w benzyl alcohol. BupivacaineN-oxide in the sustained release bupivacaine compositions can be formedby an oxidative reaction between bupivacaine and peroxides.

Methods

The peroxide content for several lots of sucrose acetate isobutyratewere determined by potentiometric titration involving iodometrictitration. The bupivacaine N-oxide levels in samples of Formulation Awere determined using HPLC with UV detection. Primary stability samplecompositions, clinical samples, and the two optimization samplecompositions of Formulation A were prepared at a scale of 150 L. Samplesused for the heating study were prepared at a scale of 2.5 L. Theheating study evaluated the effect of temperature during preparation.

Results

The levels of bupivacaine N-oxide in Formulation A on stability at 25°C./60% RH and the peroxide content in SAIB compositions used to preparesamples of Formulation A are listed in Table 10.1. The bupivacaineN-oxide data in Table 10.1 are for the longest available stability timepoints for each set of samples. These range from 3 months for the twooptimization lots, up to 36 months for the four primary stabilitysamples (each filled to 5 mL and 7.5 mL) of Formulation A and theclinical sample of Formulation A.

TABLE 10.1 Correlation of Peroxide Content of SAIB for preparing Samplesof Formulation A and Bupivacaine N-Oxide Time Observed (Months) onAmount Stability at Bupi- Pero- % 25° C./60% Orienta- vacaine xideBupivacaine RH for Data tion Composition Sample Content N-Oxide on inColumn on ID ID (ppm) Stability to the Left Stability Bupivacaine PS-A66 0.3 36 inverted Composition Bupivacaine SS-A 66 0.3 36 invertedComposition Bupivacaine PS-B 86 0.3 36 inverted Composition BupivacaineSS-B 86 0.3 36 inverted Composition Bupivacaine PS-C 60 0.3 36 invertedComposition Bupivacaine SS-C 60 0.3 36 inverted Composition BupivacainePS-D 66 0.3 36 inverted Composition Bupivacaine SS-D 66 0.3 36 invertedComposition Clinical CS-A 236 1.6% of total Bupivacaine SAIB inComposition product lot 222 15.1% of total SAIB in product lot 198 29.6%of total SAIB in product lot 211 53.7% of total SAIB in product lot

Table 10.2 summarizes the result of peroxide content from a heatingstudy that evaluated the effect of temperature during preparation.

TABLE 10.2 Peroxide Content of SAIB for preparing Samples of FormulationA and Bupivacaine N-Oxide in Optimization Lots and Heating Study TimeObserved (Months) on Amount Stability at Pero- % 25° C./60% RH Orienta-Compo- xide Bupivacaine for Data in tion sition Content N-Oxide onColumn On ID (ppm) Stability to the Left Stability Heating HS-A 184 0.66 inverted Study Heating HS-B 184 0.6 6 inverted Study Optimization OL-A 19 BQL 3 inverted Lot - 1 Optimization OL-B  19 BQL 3 inverted Lot - 2

FIG. 2 illustrates a linear regression line fitted to the SAIB peroxidecontent data versus the bupivacaine N-oxide levels data. Based on thelinear regression equation, it is estimated that the 1.0% specificationlimit for bupivacaine N-oxide corresponds to 296.4 ppm peroxide in SAIB.To ensure not exceeding the 1.0% limit for bupivacaine N-oxide, thetarget peroxide content can be adjusted to a value that corresponds to0.8% bupivacaine N-oxide. This peroxide content value is calculated tobe 232.5 ppm using the equation in FIG. 2.

To determine the fraction of bupivacaine N-oxide that may result fromthe peroxide impurities in benzyl alcohol, benzyl alcohol lots used inthe preparation of the samples of Formulation A listed in Table 10.3were examined. Table 10.3 lists the benzyl alcohol compositions withtheir determined peroxide values (PV). All of the benzyl alcoholcompositions had peroxide values of less than 0.5. The peroxide valuecan be converted to peroxide content, expressed as hydrogen peroxide, bymultiplying PV by 17. This results in peroxide content data for all thebenzyl alcohol lots as <8.5 ppm. Since the samples of Formulation Acontain benzyl alcohol and SA in a 1:3 w/w ratio, the effective peroxidecontent of benzyl alcohol that would contribute to oxidizing bupivacaineto bupivacaine N-oxide is one third that of the peroxide content ofSAIB. With this calculation, each lot of benzyl alcohol that was used inthe samples of Formulation A listed in Table 10.3 effectively had <2.8ppm (8.5 ppm divided by 3 equals 2.8 ppm) contribution to the formationof bupivacaine N-oxide. The maximum contribution to peroxide contentfrom benzyl alcohol is 85 ppm divided by 3, or 28 ppm.

TABLE 10.3 Peroxide Content of Benzyl Alcohol used for preparing samplesof Formulation A Effective Bupi- Benzyl Benzyl Benzyl vacaine AlcoholAlcohol Alcohol Compo- Benzyl Peroxide Peroxide Peroxide Compositionsition Alcohol Value (PV) Content Content ID No. ID from CofA (ppm)(ppm) Bupivacaine PS-A BA <0.5 <8.5 <2.8 Composition Composition 1Bupivacaine SS-A BA <0.5 <8.5 <2.8 Composition Composition 1 BupivacainePS-B BA <0.5 <8.5 <2.8 Composition Composition 2 Bupivacaine SS-B BA<0.5 <8.5 <2.8 Composition Composition 2 Bupivacaine PS-C BA <0.5 <8.5<2.8 Composition Composition 3 Bupivacaine SS-C BA <0.5 <8.5 <2.8Composition Composition 3 Bupivacaine PS-D BA <0.5 <8.5 <2.8 CompositionComposition 2 Bupivacaine SS-D BA <0.5 <8.5 <2.8 Composition Composition2 Clinical CS-A BA <0.5 <8.5 <2.8 Bupivacaine Composition 4 CompositionHeating HS-A BA <0.5 <8.5 <2.8 Study Composition 5 Heating HS-B BA <0.5<8.5 <2.8 Study Composition 5 Optimization OL-A BA <0.5 <8.5 <2.8 Lot -1 Composition 6 Optimization OL-B BA <0.5 <8.5 <2.8, <2.8 Lot - 2Composition 6 and BA Composition 7

Example 11

The stability of various batches of Formulation A was studied. Theresults of these exemplary batches are summarized in Tables 11.1 and11.2 and FIGS. 3-11. The stability of the samples of Formulation A inthis study was assayed using HPLC with UV detection.

Samples of Formulation A (5 mL) were examined for photostability. Fourdifferent sample lots of Formulation A (11A-11C) were characterized andsummarized in Tables 11.1 and 11.2. The photostability of each sample ofFormulation A was studied under three different conditions: 1) lightunprotected; 2) light protected using foil; and 3) light protected andpackaged. The colors exhibited by each of the tested samples as well asthe degree of coloration of the samples are summarized in Tables 11.1and 11.2. In addition, Tables 11.1 and 11.2 summarize the label strengthas well as presence of benzyl acetate and benzyl isobutyrate in thetested samples.

FIG. 3 depicts the label strength of 4 primary (5 mL) and 4 secondary(7.5 mL) lots of samples of Formulation A over a 36-month period. Thelabel strength was measured for each sample at a temperature of 25° C.and 60% relative humidity.

FIG. 4 depicts the change in the presence of the N-oxide of bupivacaine(measure in % bupivacaine N-oxide) in 4 primary (5 mL) and 4 secondary(7.5 mL) lots of samples of Formulation A over a 36-month period. Theamount of bupivacaine N-oxide in the samples was measured for eachsample at a temperature of 25° C. and 60% relative humidity.

FIG. 5 depicts the presence of 2,6-dimethylaniline (measure in ppm) in 4primary (5 mL) and 4 secondary (7.5 mL) lots of samples of Formulation Aover an 18-month period (months 18-36). The amount of2,6-dimethylaniline in the samples was measured for each sample storedat a temperature of 25° C. and 60% relative humidity. FIG. 6 depicts thepresence of 2,6-dimethylaniline in samples of Formulation A stored for a6-month period at 3 different temperatures (25° C., 30° C. and 40° C.)and 2 different relative humidities (60% RH, 75% RH).

FIG. 7 depicts the presence of benzyl acetate (measure in mg/mL) in 4primary (5 mL) and 4 secondary (7.5 mL) lots of samples of Formulation Aover a 36-month period. The amount of benzyl acetate in the samples wasmeasured for each sample stored at a temperature of 25° C. and 60%relative humidity. FIG. 8 depicts the presence of benzyl acetate insamples of Formulation A stored for a 6-month period at 3 differenttemperatures (25° C., 30° C. and 40° C.) and 2 different relativehumidities (60% RH, 750RH).

FIG. 9 depicts the presence of benzyl isobutyrate (measure in mg/mL) in4 primary (5 mL) and 4 secondary (7.5 mL) lots of samples of FormulationA over a 36-month period. The amount of benzyl isobutyrate in thesamples was measured for each sample stored at a temperature of 25° C.and 60% relative humidity. FIG. 10 depicts the presence of benzylisobutyrate in samples of Formulation A stored for a 6-month period at 3different temperatures (25° C., 30° C. and 40° C.) and 2 differentrelative humidities (60% RH, 75% RH).

FIG. 11 depicts the change in the percent SAB in 4 primary (5 mL) and 4secondary (7.5 mL) lots of samples of Formulation A over a 36-monthperiod. The change in the percent SAIB of samples of Formulation A wasmeasured for each sample stored at a temperature of 25° C. and 60%relative humidity.

TABLE 11.1 Stability Results for Formulation A-Sample 1-PhotostabilityStudy, 5 mL Acceptance Criteria Appearance Clear light yellow to amberAssay¹ solution; Degree of 93.0- Benzyl Benzyl essentially freeColoration 105.0% Acetate ^(a) Isobutyrate ^(a) Lot Size of particulateof Liquids label NMT NMT Number (mL) Condition matter NMT 6x BY1strength 20.0 mg/mL 10.0 mg/mL 11A 5 Light Pass³/Light BY4 (with 97.23.4 1.4 Storage- Yellow yellow tint), (97.1, (3.4, 3.4) (1.4, 1.4)Unprotected² BY4 (with 97.2) yellow tint) Light Pass/Yellow BY3, BY397.8 3.4 1.4 Storage- Brown (97.7, (3.4, 3.4) (1.4, 1.4) Protected,97.9) Foil Light Pass/Yellow BY3, BY3 98.4 3.4 1.5 Storage- Brown (98.6,(3.4, 3.4) (1.5, 1.4) Protected, 98.2) Package 11B 5 Light Pass/LightBY4 (with 98.7 4.1 1.6 Storage- Yellow yellow tint), (98.7, (4.1, 4.1)(1.6, 1.6) Unprotected BY4 (with 98.7) yellow tint) Light Pass/YellowBY3, BY3 99.9 4.1 1.7 Storage- Brown (100.0, (4.1, 4.0) (1.7, 1.7)Protected, 99.7) Foil Light Pass/Yellow BY3, BY3 99.7 4.1 1.7 Storage-Brown (99.5, (4.1, 4.1) (1.6, 1.7) Protected, 99.8) Package ¹Average(Individual) results reported ²Light Storage = Accelerated light storagecondition ³Pass = clear, essentially free of particulate matter

TABLE 11.2 Stability Results for Formulation A-Sample 2-PhotostabilityStudy, 5 mL Acceptance Criteria Appearance Clear light Assay¹ yellow toamber Degree of 93.0- Benzyl Benzyl solution; Coloration 105.0% Acetate^(a) Isobutyrate ^(a) Lot Size essentially free of of Liquids label NMTNMT Number (mL) Condition particulate matter NMT 6x BY1 strength 20.0mg/mL 10.0 mg/mL 11C 5 Light Pass³/Light BY4 (with 97.2 3.4 1.4 Storage-Yellow yellow tint), (97.1, (3.4, 3.4) (1.4, 1.4) Unprotected² BY4 (with97.2) yellow tint) Light Pass/Yellow BY3, BY3 97.8 3.4 1.4 Storage-Brown (97.7, (3.4, 3.4) (1.4, 1.4) Protected, 97.9) Foil LightPass/Yellow BY3, BY3 98.4 3.4 1.5 Storage- Brown (98.6, (3.4, 3.4) (1.5,1.4) Protected, 98.2) Package 11D 5 Light Pass/Light BY4 (with 98.7 4.11.6 Storage- Yellow yellow tint), (98.7, (4.1, 4.1) (1.6, 1.6)Unprotected BY4 (with 98.7) yellow tint) Light Pass/Yellow BY3, BY3 99.94.1 1.7 Storage- Brown (100.0, (4.1,4.0) (1.7, 1.7) Protected, 99.7)Foil Light Pass/Yellow BY3, BY3 99.7 4.1 1.7 Storage- Brown (99.5, (4.1,4.1) (1.6, 1.7) Protected, 99.8) Package ¹Average (Individual) resultsreported ²Light Storage = Accelerated light storage condition ³Pass =clear, essentially free of particulate matter

Example 12

Comparison of In Vitro Dissolution Profiles for Bupivacaine Formulationswith Varying Amounts of SAIB and Solvent (N=3 or 4)

To compare dissolution profiles, formulations having 12% w/w bupivacainebut differing ratios of sucrose acetate isobutyrate (SAIB)/solvent weremade and tested as described in the below Methods and Materials. Table12.1 is a summary of the compositions of the formulations tested.

TABLE 12.1 Bupivacaine/SAIB/BA (target % w/w) composition of eachformulation tested Compositions (target % w/w) Formulation Benzyl VisualVariant Bupivacaine Alcohol SAIB Appearance Control 12.0 22.0 66.0solution −30% SAIB 12.0 41.8 46.2 solution −40% SAIB 12.0 48.4 39.6solution −50% SAIB 12.0 55.0 33.0 solution −70% SAIB 12.0 68.2 19.8solution −90% SAIB 12.0 81.4  6.6 solution

In vitro release of bupivacaine for the formulations shown in Table 12.1was assessed according to the methods described in the below Methods andMaterials. FIG. 12 shows the mean cumulative release of the controlformulation (N=4), −30% SAIB formulation (N=3), −40% SAIB formulation(N=3), −50% SAIB formulation (N=4), −70% SAIB formulation (N=3), and−90% SAIB formulation (N=3).

FIG. 12 shows that the cumulative release profile of the control issimilar to those of the −30%, −40%, and −50% SAIB formulations. Thecumulative release profile of the control is faster than those of the−70% and −90% SAIB formulations. Using the average dissolution data fromthe control as a reference, the similarity factor f₂ and differencefactor f₁ were calculated for the −30%, −40%, −50%, −70%, and −90% SAIBformulations. See below for an explanation of the f₁ and f₂ factors. Asshown in Table 12.2, the −30%, −40%, and −50% SAIB formulations had f₁and f₂ factors that would indicate that they are not different relativeto the control.

TABLE 12.2 Difference (f₁) and Similarity (f₂) Factors of FormulationsRelative to Control Compositions (target % w/w) Difference SimilarityFormulation Benzyl Factor Factor Variant Bupivacaine Alcohol SAIB f₁ f₂Control 12.0 22.0 66.0 NA NA −30% SAIB 12.0 41.8 46.2 4 82 −40% SAIB12.0 48.4 39.6 7 68 −50% SAIB 12.0 55.0 33.0 8 62 −70% SAIB 12.0 68.219.8 18 45 −90% SAIB 12.0 81.4  6.6 29 36Comparison of In Vitro Dissolution Profiles for Bupivacaine Formulationswith Varying Amounts of SAIB and Solvent (N=12)

To compare dissolution profiles, formulations having 12% w/w bupivacainebut differing ratios of sucrose acetate isobutyrate (SAIB)/solvent weremade and tested as described below. Table 12.3 is a summary of thecompositions of the formulations tested.

TABLE 12.3 Bupivacaine/SAIB/BA (target % w/w) composition of eachformulation tested Compositions (target % w/w) Formulation Benzyl VisualVariant Bupivacaine Alcohol SAIB Appearance Control 12.0 22.0 66.0solution +20% SAIB 12.0 8.8 79.2 suspension −20% SAIB 12.0 35.2 52.8solution −70% SAIB 12.0 68.2 19.8 solution

In vitro release of bupivacaine for the formulations shown in Table 12.3was assessed according to the methods described in the below Methods andMaterials. FIG. 13 shows the mean cumulative release of the controlformulation (N=12), +20% SAIB formulation (N=12), −20% SAIB formulation(N=12), and −70% SAIB formulation (N=12).

FIG. 13 shows that the release profile of the control is similar tothose of the +20% and −20% SAIB formulations. The cumulative releaseprofile of the control is faster than that of the −70% SAIB formulation.Using the average dissolution data from the control as a reference, thesimilarity factor f₂ and difference factor f₁ were calculated for the+20%, −20%, and −70% SAIB formulations. See below for an explanation ofthe f₁ and f₂ factors. As shown in Table 12.4, the +20% and −20% SAIBformulations had f₁ and f₂ factors that would indicate that they are notdifferent relative to the control.

TABLE 12.4 Difference (f₁) and Similarity (f₂) Factors of FormulationsRelative to Control Compositions (target % w/w) Formulation BenzylDifference Similarity Variant Bupivacaine Alcohol SAIB Factor f₁ Factorf₂ Control 12.0 22.0 66.0 NA NA +20% SAIB 12.0 8.8 79.2 3 84 −20% SAIB12.0 35.2 52.8 3 86 −70% SAIB 12.0 68.2 19.8 18 44Comparison of In Vitro Dissolution Profiles for Bupivacaine FormulationsMade with Variable Heating

To compare dissolution profiles, a control formulation and aheat-stressed SAIB formulation were made and tested as described thebelow Methods and Materials. Both the control and heat-stressed SAIBformulations nominally consisted of 12% w/w bupivacaine, 22% w/w benzylalcohol, and 66% w/w SAIB.

In vitro release of bupivacaine for the formulations described above wasassessed according to the methods described below. FIG. 14 shows themean cumulative release of the control formulation (N=12) andheat-stressed SAIB formulation (N=12).

Comparison of the heat-stressed SAIB formulation with the control inFIG. 14 shows that both formulations were similar from 1 to 18 hours.Starting at 24 hours, the release profile of the heat-stressed SAIBformulation levels off reaching about 66% drug released at 72 hours.

Methods and Materials

Cumulative Release of Bupivacaine In Vitro

The in vitro cumulative release of bupivacaine from formulations wasdetermined as follows.

Materials

The bupivacaine formulations, other than the heat-stressed formulation,were prepared by dissolving appropriate amounts of bupivacaine inappropriate amounts of benzyl alcohol (BA), adding an appropriate amountof sucrose acetate isobutyrate (SAIB), and stirring not less than 45minutes at about 35° C. For the heat-stressed SAIB formulation, the sameprocess was followed except the SAIB was pre-heated in an oven at 225°C. for 4 hours before use. A portion of the pre-heated SAIB was testedand found to have 98% SAIB remaining.

Dissolution Testing

Dissolution was measured using a USP Apparatus II. Approximately 0.5 mLof each formulation was loaded via cannula and syringed into 900 mL±5 mLof 37±0.5° C. dissolution media (phosphate buffer at pH 7.4±0.05 with0.03% sodium lauryl sulfate). The USP Apparatus II was set at 50 RPM,and samples were collected at 1, 4, 8, 12, 18, 24, 36, 48, and 72 hours.The number of replicates (N) per sample per time point varied asdescribed above. The collected samples were assayed for bupivacainecontent by HPLC.

Statistical Analysis

The dissolution profile comparisons were conducted using a differencefactor (f₁) and a similarity factor (f₂) approach (FDA Guidance forIndustry “Dissolution Testing of Immediate Release Solid Oral DosageForms” August 1997). The difference factor calculates the percentdifference between two curves at each time point and is a measurement ofthe relative error between the two curves, as shown in Equation 1:

f ₁={[Σ_(t=1) ^(n) |R _(t) −T _(t)|]/[Σ_(t=1) ^(n) R _(t)]}×100  (1)

In Equation 1, R_(t) and T_(t) represent the mean dissolution resultsobtained from the reference and test lots respectively, at eachdissolution time point t, while n represents the number of dissolutiontime points.

The similarity factor (f₂) is a logarithmic reciprocal square roottransformation of the sum of squared error and is a measurement of thesimilarity in the percent dissolution between the two curves, as shownin Equation 2.

f ₂=50×log {[1+(1/n)Σ_(t=1) ^(n)(R _(t) −T _(t))²]^(−0.5)×100}  (2)

The terms in Equation 2 are as defined in Equation 1. The value of f₂can range from 0 to 100, with a larger f₂ indicating greater similaritybetween the reference and test article. A f₂ value of 50 corresponds toan average difference of 10% at each time point.

For two curves to be considered similar, the f₁ value should be close to0, and the f₂ value should be close to 100. Generally, f₁ values of 0-15and f₂ values of 50-100 ensure sameness or equivalence of two curves,and thus of the performance of the test and reference products.

Example 13

A randomized, double-blinded, active- and placebo-controlled study wasconducted to evaluate the efficacy and safety of Formulation A forpost-operative pain control in patients following arthroscopic shouldersurgery.

Objectives

The objective was to identify the optimal dose of Formulation A forpost-operative pain control administered into the subacromial space inpatients undergoing elective arthroscopic shoulder surgery on the basisof efficacy, pharmacokinetics (PK), and safety evaluations.

Methods

The study was a parallel group, randomized, double-blinded, active- andplacebo-controlled, dose response trial of Formulation A withpost-operative assessments of pain intensity (PI), PK, safety, andhealth economics in patients undergoing elective arthroscopic shouldersurgery, comprising up to a 14-day screening period, a 7-daypost-surgical period, an EOT visit at Day 14, and a follow-up visitafter six months.

Composition: Formulation A Active ingredient: Bupivacaine base Inactiveingredients: Sucrose acetate isobutyrate, benzyl alcohol Administration:Varied, based on surgical procedure, interstitial (FDA Code 088) eitherby tissue infiltration, injection or needle-free deposition for generalsurgical applications. Strength: 132 mg/mL, 660 mg bupivacaine

Composition Placebo Active ingredient: Not applicable Inactiveingredients: Sucrose acetate isobytyrate, benzyl alcohol Administration:Varied, based on surgical procedure, interstitial (FDA Code 088) eitherby tissue infiltration, injection or needle-free deposition for generalsurgical applications.

Composition: Active Control Active ingredient: Bupivacaine HCl Inactiveingredients: Sterile isotonic solution containing sodium chlorideAdministration: Varied, based on surgical procedure, interstitial (FDACode 088) either by tissue infiltration, injection or needle-freedeposition for general surgical applications. Strength: 20 mL of 2.5mg/mL, 50 mg

Patients were screened 1 to 14 days before surgery at which timeinformed consent was obtained. Surgery was performed and the trial drugadministered on Day 0. The trial was planned to be divided into twosequential cohorts, each with three treatment groups (a, b and c). Afterscreening, the first patients were randomized 2:1:1 to the treatmentgroups in cohort 1: 1a) 5 mL Formulation A (660 mg bupivacaine)subacromial administration; 1b) 5 mL placebo subacromial administration;and 1c) 20 mL standard bupivacaine hydrochloride (HCl) 0.25% w/v (50 mgbupivacaine) administered subacromially. After finalization of cohort 1,data was analyzed and, based on the efficacy, safety and PK resultspresented in this clinical trial report (CTR), a decision was maderegarding whether the second cohort (cohort 2) would be initiated, andwhether new patients would be recruited and treated at the higher dosageof Formulation A: 2a) 7.5 mL Formulation A (990 mg bupivacaine)administered subacromially; 2b) 7.5 mL placebo administeredsubacromially; and 2c) 20 mL standard bupivacaine HCl (50 mgbupivacaine) administered subacromially. The Data Review Committeerecommended that an increase in dose to 7.5 mL of Formulation A was notexpected to provide a clinically significant improvement in efficacy.Therefore, the trial did not include the 7.5 mL Cohort 2.

All patients received paracetamol (4 grams/day; 2 grams/day for bodyweight <66 kg for the first 72 hours) as background treatment. In casesufficient pain relief was not obtained, patients were allowed rescuemedication in the form of morphine administered intravenously or orally,which consisted of oral morphine 10 mg at 1-hour intervals or, if unableto tolerate orally intake, intravenous (IV) morphine 2 g at 5-minuteintervals. After 72 hours, subjects were allowed paracetamol and oralmorphine on an as-needed basis. Patients recorded pain intensity as wellas rescue medication in an electronic diary (eDiary).

Diagnosis and Main Criteria for Inclusion/Exclusion:

Subjects with subacromial impingement syndrome and an intact rotatorcuff established by magnetic resonance imaging (MRI) and who weresuitable for general anesthesia were eligible for inclusion. Patientswith other shoulder pathology or who had serious medical conditions orwho were unable to tolerate the study drug were excluded.

Formulation a, Dose and Mode of Administration:

9.0 mL Formulation A (132 mg bupivacaine/mL) per vial. Followingsurgery, 5 mL Formulation A (660 mg bupivacaine) (cohort 1) wasadministered into the subacromial space through one of the arthroscopicportals or by injection through intact skin under direct arthroscopicvision to confirm placement of the needle tip within the suvacromialspace. Formulation A was administered once only following completion ofsurgery.

Reference Composition, Dose and Mode of Administration:

This trial was placebo-controlled and had an active comparator arm.Placebo (5 mL) was administered using the same method as for FormulationA. The active comparator was standard bupivacaine HCl (20 mL of 2.5mg/mL) was administered subacromially as a single dose.

Criteria for Evaluation Efficacy

Primary: The study had two primary endpoints. The primary efficacyendpoints were: PI on movement area under the curve AUC over the timeperiod 1 to 72 hours post-surgery measured by an 11-point NumericalRating Scale (NRS); and total use of opioid rescue analgesia 0 to 72hours after surgery. For the primary endpoints to be met,non-inferiority of PI on movement compared to placebo as well assuperiority in total use of opioid analgesia needed to be shown. PI “onmovement” reported on the NRS scale was summarized by treatment groupand time, using descriptive statistics for continuous variables.

Secondary: Time to first opioid rescue medication usage; Opioid-RelatedSymptom Distress Scale (OR-SDS) score Days 0 to 7 post-surgery; PI atrest AUC over the period 1 to 72 hours post-surgery; patient's paintreatment satisfaction score on Day 4 post-surgery; proportion ofpatients who were dischargeable (according to the Post-AnaestheticDischarge Scoring System [PADS]) on Days 1, 2, 3, 4 and 7 post-surgery;and proportion of patients who had returned to work by Day 14post-surgery. Time to first opioid rescue medication usage was definedas the duration between time of trial drug administration and the timeof first opioid use

Pharmacokinetics

Total and free bupivacaine plasma concentrations were measured for theFormulation A and standard bupivacaine HCl groups for evaluation ofbupivacaine PK, including maximum concentrations of bupivacaine.Additionally, alpha 1 acid glycoprotein (AAG) plasma concentrations weremeasured in these two groups for correlation with free bupivacaineconcentrations.

Pharmacokinetic/pharmacodynamic (PK/PD) relationships were to beassessed as part of central nervous system (CNS) toxicity monitoring andcardiac monitoring. For patients not selected for PK-profiling, if acardiac or CNS event occurred that met the criteria for a seriousadverse event (SAE) or a severe non-SAE, a blood sample for PK analysiswas to be taken as close to the event as possible.

Safety

The incidence of adverse events (AEs); the incidence ofbupivacaine-related CNS side effects; clinical laboratory tests; vitalsigns; 12-lead ECGs; and physical examinations.

Other Assessments

Evaluation by the investigator of wound healing and tissue conditions atthe surgical wound on Days 7 and 14, and at the 6-month follow-up visit.An MRI of the shoulder as well as a functionality assessment of theshoulder using the Constant-Murley score were to be performed at the6-month follow-up visit.

Results

Primary Efficacy Endpoints

The mean PI on movement AUC over the time period 1 to 72 hourspost-surgery (ITT population) is summarized in Table 13.1. TheFormulation A group was shown to be statistically superior over placebofor the time period 1 to 72 hours post-surgery (p-value: 0.012). The PIon movement over time for the ITT population is shown in FIG. 15.

TABLE 13.1 Pain intensity on movement, mean AUC (LOCF) (ITT population)Treatment Variable n Mean SD 95% CI p-value Formulation A AUC (1-24 535.16 2.04 5 mL AUC (24-48 51 5.38 2.23 AUC (48-72 53 4.87 2.33 AUC (1-4853 5.31 1.94 AUC (1-72 53 5.16 1.94 Placebo AUC (1-24 24 7.31 1.89 5 mLAUC (24-48 24 6.62 1.93 AUC (48-72 25 5.57 2.06 AUC (1-48 25 6.88 1.82AUC (1-72 25 6.43 1.77 Standard AUC (1-24 29 5.82 2.30 Bupivacaine AUC(24-48 29 5.31 2.70 HCl AUC (48-72 29 4.38 2.48 AUC (1-48 29 5.56 2.43AUC (1-72 29 5.16 2.38 Difference: AUC (1-24 106 −2.14 0.52 FormulationA AUC (24-48 104 −1.22 0.58 5 mL minus AUC (48-72 107 −0.68 0.56 Placebo5 mL AUC (1-48 107 −1.56 0.50 [−2.56; −0.56] 0.002 AUC (1-72 107 −1.270.50 [−2.25; −0.28] 0.012 Difference: AUC (1-24 106 −0.66 0.49Formulation A AUC (24-48 104 0.03 0.54 5 mL minus AUC (48-72 107 0.480.54 Standard AUC (1-48 107 −0.27 0.48 [−1.22; 0.69] Bupivacaine AUC(1-72 107 −0.02 0.47 [−0.96; 0.92] HCl n = number of patients withavailable data; SD = standard deviation; CI = confidence interval; AUC =area under the curve; LOCF = last observation carried forward; ITT =intention to treat. LS Mean difference and standard error is presentedfor treatment differences. P-value from ANOVA with treatment group andtrial site in the model.

Significantly less opioid rescue medication was taken by subjectstreated with Formulation A than placebo (Table 13.2). The mediancumulative IV morphine-equivalent dose of opioids from 0 to 72 hoursafter treatment was 4.0 mg for the Formulation A group and 12.0 mg forthe placebo group (p=0.0130). The median cumulative dose was 8.0 mg forthe bupivacaine HCl group. Postoperative opioid rescue medication usewas analyzed nonparametrically because it did not meet prespecifiednormality assumptions. The percentage of subjects that remained opioidfree during the 72 hours after surgery was also significantly greater inthe Formulation A group than the placebo group: 39.6% v. 16.0%(P=0.027). The percentage abstaining from opioids in the bupivacaine HClgroup was 27.6%.

TABLE 13.2 Total IV morphine equivalent dose of opioid rescue medicationtaken from 0-72 hours after surgery, ITT population Placebo FormulationA Bupivacaine HCl (N = 25) (N = 53) (N = 29) Min, max, mg 0, 92 0, 1760, 66 Median, mg 12.0 4.0 8.0 Median difference −8.0 vs placebo, mg^([1]) 95% CI −12.0, 0.0 P-value ^([2]) 0.0100 Median difference vsbupivacaine HCl, mg ^([1]) 0.0 95% CI −4.6, 0.0 P-value ^([2]) — CI,confidence interval; ITT, intent-to-treat; IV, intravenous ^([1])Hodges-Lehmann estimates for median difference ^([2]) Wilcoxon rank-sumtest

Secondary Efficacy Variables

Treatment with Formulation A significantly prolonged the time to firstpostsurgical use of opioid rescue medication compared with placebo(Table 13.3). The median time to first use was 12.4 hours for theFormulation A group and 1.2 hours for the placebo group (p=0.0137). Themedian time to first use was 1.4 hours for the bupivacaine HCl group.

TABLE 13.3 Time to first use of opioid rescue medication, ITT populationBupivacaine Placebo Formulation A HCl (N = 25) (N = 53) (N = 29) Min,Max 0.0, 14.2 0.0, 36.6 0.0, 10.9 Median (95% CI), hours ^([1]) 1.2(0.7, 1.5) 12.4 (1.2, −) 1.4 (1.0, 4.1) P-value for median 0.0137difference vs placebo ^([2]) P-value for median — difference vsbupivacaine HCl ^([2]) CI, confidence interval; ITT, intention-to-treat;min, minimum; max, maximum Note: Subjects who did not use opioid rescuemedication on-study were censored at their last study visit. ^([1])Median time from study treatment to administration of an opioidmedication reported as a concomitant medication, based on Kaplan-Meiersurvival estimates. ^([2]) Log-rank test.

Comparison of the OR-SDS scores on Day 0 to 7 did not reveal anystatistically significant differences between treatment groups(Formulation A versus placebo and Formulation A versus standardbupivacaie HCl).

Overall, 81 patients (75.7% of patients in the ITT population)experienced at least one opioid-related side effect in the period Day 0to 3, the frequency and number of patients experiencing allopioid-related side effects was similar across all treatment groups.Drowsiness, fatigue and dizziness were the most frequent opioid-relatedsymptoms recorded for the total (ITT) population in the period Day 0 to3.

Table 13.4 summarizes PI at rest normalized AUC 1-72 hours post surgeryfor the ITT population. As with P; on movement, Formulation Asignificantly reduced PI over 72 hours compared to Placebo. Thedifference between Formulation A and Bupivacaine HCl was notsignificant.

TABLE 13.4 Pain intensity at rest normalized AUC 1-72 hours, ITTpopulation Placebo Formulation A Bupivacaine HCl (N = 25) (N = 53) (N =29) Mean (SD) ^([1]) 3.43 (2.05) 2.50 (1.34) 2.33 (1.76) LS meandifference (SE) −0.91 (0.39) vs placebo ^([1]) 95% CI −1.68, −0.14P-value ^([2]) 0.021 LS mean difference (SE) 0.12 (0.37) vs bupivacaineHCl ^([1]) 95% CI −0.62, 0.85 P-value ^([2]) — AUC, area under thecurve; CI, confidence interval; SD, standard deviation; SE, standarderror of the mean ^([1]) ANOVA model with treatment group and country asfactors; missing pain scores imputed by last observation carried forwardfor subjects discontinuing before 72 hours, first observation carriedbackward for missing initial pain scores, and linear interpolation formissing pain scores between two non-missing scores. ^([2]) t-test in anANOVA model.

On Day 4, the majority of patients were either satisfied (59.8% ofpatients) or very satisfied (27.1% of patients) with the pain treatmentthey had received for their surgery. Only one patient was verydissatisfied with her pain treatment (in the Formulation A group) andfour patients were dissatisfied (three in the Formulation A group andone in the standard bupivacaine HCl group).

There were no statistically significant differences in the patients'pain satisfaction score (on Day 4 after surgery had been performed)between the treatment groups; Formulation A against placebo (p-value:0.995) and Formulation A against standard bupivacaine HCl (p-value0.699).

There were no statistically significant differences between thetreatment groups in the patients' home-readiness on either day. The oddsratio for the pair-wise comparisons of Formulation A against placebo andFormulation A against standard bupivacaine HCl were 1.894 (CI: 0.693;5.177, p-value: 0.213) and 1.240 (CI: 0.457; 3.366, p-value 0.673) onDay 1 (afternoon) and 2.654 (CI: 0.948; 7.428, p-value: 0.063) and 1.137(CI: 0.419; 3.089, p-value 0.801) on Day 2 (afternoon).

There were also no statistically significant differences between thetreatment groups in the number of patients who had returned to workafter 14 days. The odds ratio for the pair-wise comparisons ofFormulation A against placebo and Formulation A against standardbupivacaine HCl were 1.210 (CI: 0.325; 4.498, p-value: 0.776) and 1.505(CI: 0.358; 6.329, p-value 0.577) on Day 14.

Pharmacokinetics

Total and free (unbound) bupivacaine plasma concentrations in patientsundergoing arthroscopic subacromial decompression were measuredfollowing either administration of 5.0 mL Formulation A (660 mgbupivacaine) or administration of 20 mL standard bupivacaine HCl (50 mgbupivacaine). Using non-compartmental methods the following PKparameters were calculated from the plasma concentrations of eachcompound: area under the plasma concentration vs. time curve until thelast measured concentration (AUC_(t)), area under the plasmaconcentration vs. time curve extrapolated until infinity (AUC_(inf)),the maximum concentration (C_(max)), the time of its occurrence(t_(max)) and the apparent terminal elimination half-life (t_(1/2)). Dueto the extended release characteristics of the Formulation A,bupivacaine plasma concentrations increased relatively slowly andextended profiles of both total and free bupivacaine were observed. At96 h post dose there are still measureable plasma concentrations in mostpatients of the Formulation A group. Bupivacaine HCl plasmaconcentrations were considerably lower than in the Formulation A groupat all timepoints. The average plasma protein binding of bupivacaine wasapproximately 5.2%; free bupivacaine plasma concentrations generallyparalleled those of total bupivacaine. There was a large interindividualvariability of C_(max) of both total and free bupivacaine. The highestindividual C_(max)-values of total and free bupivacaine were 1.320 mg/Land 0.074 mg/L, respectively. Note: Table 13.5 presents Geometric mean,±68^(th) percentile for C_(max) rather than absolute min, max.

Mean C_(max) and AUC of bupivacaine in the current study wereconsiderably lower than expected from historic studies. A variableamount of the administered dose may have escaped from the wound betweenadministration and closure of the wound, possibly leading to asignificantly reduced exposure to bupivacaine.

There was no apparent influence of either total or free bupivacaine onany cardiovascular parameters (QTcF, QTcB and QRS) even at the highestobserved bupivacaine plasma concentrations. The few reported CNS sideeffects did not correlate with either C_(max) or t_(max) of freebupivacaine. Geometric mean total and free bupivacaine plasmaconcentration following bupivacaine concentration following FormulationA or standard bupivicane are presented in FIG. 16.

FIG. 17 shows a correlation of all individual plasma concentrations offree versus total bupivacaine for Formulation A. Free bupivacaine plasmaconcentrations increase in proportion with total bupivacaineconcentrations. The slope of the regression line indicates the averagefree fraction (5.2%) over all timepoints and all patients. The plot alsoshows a high interindividual variability of the free fraction ofbupivacaine, which means that high total bupivacaine concentrations donot necessarily imply high free bupivacaine concentrations and viceversa. A summary of the plasma PK-parameters of total and freebupivacaine following Formulation A or standard bupivacaine is presentedin Table 13.5.

TABLE 13.5 Plasma PK-parameters of total and free bupivacaine followingadministration of Formulation A or standard bupivacaine HCl:PK-parameter Standard Standard Mean Formulation A Formulation Abupivacaine HCl bupivacaine HCl (min, max) (total) (free) (total) (free)t_(1/2) 16.4 15.8 5.93 6.65 [h] (8.4, 29) (5.9, 35) (2.6, 9.6) (2.9,15.2) t_(max) median 5.94 4.00 1.03 1.03 [h] (0, 24) (1.0, 24.0) (0.92,12.0) (0.92, 12.0) C_(max) 593 36.3 90 5.0 [ng/mL] (70, 1320) (2.5, 74)(8, 195) (0.3, 10.1) AUC_(t) 14.98 0.795 0.686 0.033 [mg · h · L⁻¹](6.47, 34.69) (0.323, 1.96) (0.249, 1.90) (0.010, 0.102) AUC_(inf) 193951045 940 48 [h.ng/mL] (1030, 55370) (44, 2306) (30, 2210) (0.7, 134)

Safety

There were no deaths in the trial and six patients experienced one SAE(one pregnancy case was reported as SAE). One SAE (pulmonary arterialhypertension, reported 113 days after treatment with Formulation A) wasconsidered related to trial drug. Overall, 37 patients (34.6%)experienced at least one TEAE (65 TEAEs were reported in total), ofwhich the majority were of mild or moderate intensity. Nine patients(8.4%) reported TEAEs that were considered to be related to treatmentwith no notable differences between treatment groups. The most commonlyreported TEAEs (see Table 13.6) were within the following System OrganClasses (SOCs): Nervous system disorders; Investigations; andGastrointestinal disorders. The most commonly reported events (bypreferred term) were nausea, headache and musculoskeletal pain (4.7% ofpatients for each). No patients withdrew due to a TEAE. Between Day 0and Day 3, three patients in the safety population reported six CNSTEAEs.

The majority of patients in each treatment group had haematology andclinical chemistry parameter values that were either normal or wereabnormal but not clinically significant throughout the trial. Clinicallysignificant clinical chemistry abnormalities were reported for fourpatients (two in the placebo group and one each in the Formulation A andstandard bupivacaine HCl groups); the vast majority of increases ordecreases were in line with what could be expected after the surgicalinsult performed. They were assessed to be of no major safety concern.

There were no important differences in the mean and median bloodpressure and heart rate on any day from screening to Day 7. There was nosignificant effect of Formulation A on ECG parameters.

Surgical site healing and/or local tissue conditions were as expected inall patients examined at Day 7, at EOT and at the 6-month follow-upvisit. No patients were recorded as experiencing unexpected surgicalsite healing throughout the trial.

For the vast majority of patients analysed, MRI results from the MRIscan performed at the 6-month follow-up reflected changes from baselinethat were consistent with either the surgical procedure insultinjection; there were no notable differences between the Formulation Aand standard bupivacaine groups.

TABLE 13.6 Summary of TEAEs by primary SOC (>2% total), preferred termand treatment group (safety population) Formulation A Placebo Standard 5mL 5 mL Bupivacaine HCl Primary SOC N = 53 N = 25 N = 29 Preferred termn % n % n % All TEAEs 16 30.2 10 40.0 11 37.9 Nervous system disorders 59.4 2 8.0 4 13.8 Headache 3 5.7 1 4.0 1 3.4 Investigations 5 9.4 2 8.0 26.9 Alanine aminotransferase increased 1 1.9 2 8.0 0 0.0Gastrointestinal disorders 2 3.8 3 12.0 1 3.4 Nausea 1 1.9 3 12.0 1 3.4Cardiac disorders 1 1.9 2 8.0 3 10.3 Musculoskeletal and connectivetissue disorders 3 5.7 1 4.0 2 6.9 Musculoskeletal pain 2 3.8 1 4.0 26.9 Skin and subcutaneous tissue disorders 2 3.8 2 8.0 2 6.9 Injury,poisoning and procedural complications 3 5.7 1 4.0 0 0.0 Generaldisorders and administration site 1 1.9 2 8.0 0 0.0 conditionsRespiratory, thoracic and mediastinal disorders 1 1.9 0 0.0 2 6.9Primary SOCs are presented in descending frequency. Preferred terms aresorted within primary SOC in descending total frequency, based onMedDRA. A patient with multiple occurrences of a TEAE under onetreatment was counted only once in the preferred term for thattreatment. Apatient with multiple TEAEs within a primary SOC was countedonly once in the total row. MedDRA = Medical dictionary for regulatoryactivities; N = number of patients in a treatment group; n = number ofpatients with at least one event in the category; % = percentage ofpatients with at least one event in the category based on N; SOC =system organ class; TEAE = treatment-emergent adverse event.

Conclusions

Efficacy

-   -   Superiority of Formulation A to placebo was shown for mean PI on        movement 1 to 72 hours post-surgery. Superiority over standard        bupivacaine HCl was not met.    -   The total use of rescue analgesia at 0 to 72 hours for the        Formulation A treatment group was statistically superior to        placebo but not for standard bupivacaine HCl. The lack of        statistical significance over bupivacaine HCl may have been a        result of the small size of the study and the effects of        background and rescue analgesia. Subjects in the bupivacaine HCl        group used twice as much (based on median amount) opioid rescue        medication as those in the Formulation A group.    -   Overall Formulation A demonstrated analgesic and opioid-sparing        effects against placebo.    -   Secondary efficacy endpoints, with the exception of PI at rest 1        to 72 hours postsurgery, did not reach statistical significance.        Secondary efficacy analyses supported the results of the primary        endpoint analyses.

Pharmacokinetics

-   -   PK-profiles supported the extended release characteristics of        the Formulation A providing long-lasting plasma concentrations        with a median Tmax of approximately 6 hours post dose. In        contrast, plasma concentrations following standard bupivacaine        were considerably lower than in the Formulation A at all        timepoints. The average percentage of unbound bupivacaine was        similar to the values known from literature for comparable        studies.    -   The highest individual plasma concentrations of total and free        bupivacaine were considerably lower than reported concentrations        for the onset of potential CNS and/or cardiovascular        side-effects. AAG plasma concentrations increased as expected        post surgery, causing a slight decrease in the percentage of        unbound bupivacaine.    -   There was no apparent influence of either total or free        bupivacaine on any cardiovascular parameters (QTcF, QTcB and        QRS) even at the highest observed bupivacaine plasma        concentrations.

Safety

-   -   The incidence and severity of treatment-emergent adverse events        were similar for all treatment groups, and no functional or        radiographic differences were noted at 6-month follow-up.    -   Formulation A was safe and well-tolerated, with no long-term        safety signals observed at 6-month follow-up.    -   There were no deaths and the incidence of SAEs in this trial was        low; one SAE was considered related to trial drug (in the        Formulation A group).    -   In terms of systemic safety, Formulation A, standard bupivacaine        HCl and placebo were generally safe and well tolerated. There        were no notable differences between treatment groups regarding        bupivacaine-related side effects. This suggests that        concentrations of free bupivacaine remained below or at the low        end of reported CNS toxicity threshold levels. Additionally, the        reported CNS side effects did not correlate with either C_(max)        or t_(max) of free bupivacaine.    -   There was no effect of Formulation A on ECG parameters.    -   There were no clinically meaningful differences between        treatment groups regarding changes in the shoulder functionality        test (Constant-Murley score) from baseline to 6 months        follow-up.    -   There were no differences between treatment groups regarding        wound healing and local tissue conditions.

Example 14

A clinical trial was conducted to explore therapeutic benefits of 5.0 mLFormulation A administered into the subacromial space in patientsundergoing arthroscopic subacromial decompression. This trial furtherinvestigated systemic and local safety of Formulation A as compared toplacebo in patients who will receive analgesic supplementation as neededwith oral opioids per common clinical practice.

Objectives

Primary objective—Explore analgesic effectiveness and characterize thesafety profile of Formulation A in an orthopedic surgical model comparedto placebo.

Secondary objective—Explore the reduction in frequency of opioid-relatedadverse events (AEs) by Formulation A in an orthopedic surgical modelcompared to placebo.

Methods

The study was a randomized, double-blind, multi-center,placebo-controlled, parallel-group trial of a single dose of 5.0 mLFormulation A in subjects undergoing arthroscopic shoulder surgery.Subjects were assessed for pain and supplemental analgesia recorded(efficacy endpoints) and AEs, surgical site healing, local tissuecondition, laboratory tests, physical examination and vital signs(safety endpoints).

Composition: Formulation A Active ingredient: Bupivacaine base Inactiveingredients: Sucrose acetate isobutyrate, benzyl alcohol Administration:Varied, based on surgical procedure, interstitial (FDA Code 088) eitherby tissue infiltration, injection or needle-free deposition for generalsurgical applications. Strength: 132 mg/mL, 660 mg bupivacaine

Composition Placebo Active ingredient: Not applicable Inactiveingredients: Sucrose acetate isobytyrate, benzyl alcohol Administration:Varied, based on surgical procedure, interstitial (FDA Code 088) eitherby tissue infiltration, injection or needle-free deposition for generalsurgical applications.Number of subjects: 60 subjects were enrolled in the study. All 60subjects enrolled in the study received at least part of a dose ofFormulation A or placebo and have been included in the Modified IntentTo Treat (MITT) population and the Safety Population. Fifty eightsubjects were included in the Per-Protocol Population (subjects thatreceived a complete administration of Formulation A or placebo, metsurgical and anesthesia requirements, successfully underwent thesurgical procedure and had at least one post-dose pain intensityrecorded).Diagnosis and criteria for inclusion: Male and female subjects, aged 18to 65 years with clinical syndrome of subacromial impingement andscheduled for arthroscopic shoulder surgery; with American Society ofAnesthesiologists (ASA) Physical Status Classification of P1 or P2 basedon medical history, physical exam, 12 lead electrocardiogram (ECG) andlaboratory tests; systolic blood pressure ≤139 mmHg and diastolic bloodpressure ≤89 mmHg; willing to use medically acceptable method ofcontraception, and to refrain from strenuous activities and providewritten consent were eligible to participate in the study.Exclision Criteria: Subjects with glenohumeral arthritis; major or fullthickness rotator cuff tears diagnosed by Magnetic Resonance Imaging(MRI); prior arthroscopic surgery or open surgery on the study shoulder;chronic pain conditions requiring continuous use of corticosteroidsfor >three months; fibromyalgia; rheumatoid arthritis; sero-negativeinflammatory athropathies; calculated creatinine clearance <30 mL/min;pregnant or lactating; receiving more than 20 mg of hydrocodone daily(or equivalent) for three or more days within seven days of surgery;opioid tolerance; required use of non-steroidal anti-inflammatory drugs(NSAIDs) within 24 hours of surgery; regular use of anticonvulsants,antiepileptics, antidepressants, or monoamine oxidase inhibitors;regular use of drugs known to prolong QTc interval within seven days ofsurgery or five times the drugs half life whichever was longer; knownhypersensitivity to local anesthetic agents of the amide type ormorphine or other opioids; conditions contraindicated for use ofopioids; known or suspected abuse of opioids, illicit drugs or alcoholabuse; participation in another trial within 30 days of surgery; notsuitable according to the InvestigatorSurgical Requirements: The subject was not to receive InvestigationalProduct if the following requirements were not met: index procedure wassubacromonial decompression performed arthroscopically; other proceduresincluded inspection of glenohumeral joint, synovectomy, removal or loosebody, minor debridement of articular cartilage, minor debridement orminor repair of rotator cuff, distal clavicle excision, bursectomy,resection of coracoacromial ligament and subacromial spurs; any conduitbetween the subacromial space and glenohumeral joint that would allowseepage and entrapment of the Investigational Product in the jointcapsule were to be avoided; procedures for shoulder instability were notallowed; biceptal tenodesis or tenotomy were not allowed.Anesthesia Requirements: The arthroscopic shoulder surgery was performedunder general anesthesia with propofol induction using intravenous (IV)fentanyl or equivalent; use of local anesthetics for wound perfusion ornerve blocks during the shoulder surgery was not allowed; use of NSAIDSduring the shoulder surgery was not allowed; epinephrine could be usedin perfusion solution for reduction of bleeding; short-acting opioidsused during general anesthesia were not restricted, post-operativeopioids given prophylactically for pain were not allowed; antiemeticmedications used for general anesthesia were not restricted,post-operative antiemetic medications were not given prophylactically.Formulation A: Single dose of 5.0 mL Formulation A (132 mg/mL, 660 mgbupivacaine) injected into the subacromial space on completion ofarthroscopic shoulder surgery. The formulation includes 3 components(sucrose acetate isobutyrate 66 wt %, benzyl alcohol 22.0 wt %, andbupivacaine base 12.0 wt %) that are administered together as a sterilesolution.Reference therapy, dose and mode of administration: Single dose of 5.0mL placebo composition was injected into the subacromial space oncompletion of arthroscopic shoulder surgeryDuration of Treatment: The study was expected to be approximately 4weeks in duration per subject. This comprised; a 14 day screeningperiod, a single dose administration on the day of surgery, and afollow-up period of 14 days.

Criteria for Evaluation:

Assessment for efficacy: Shoulder pain intensity ‘on movement’; Use ofsupplemental analgesia for post-operative pain relief.

Assessment of safety: Frequency and severity of AEs; surgical sitehealing and local tissue condition evaluation; Laboratory tests(chemistry, hematology and urinalysis); Physical examination, ECGs andvital signs.

Statistical Methods:

Randomization: Patients will be randomized (2-to-1 ratio) to FormulationA or Placebo.

Co-Primary Efficacy Endpoints:

Mean Pain Intensity on Movement Area Under the Curve (AUC) normalizedover the time period 0 to 72 hours post-dose and Mean total IVmorphine-equivalent dose during the period 0 to 72 hours post-dose.

Results Efficacy Results: Pain Intensity Normalized AUC Over 0-72 HoursPost-Dose

Pain intensity normalized AUC over 0-72 hours was compared betweentreatment groups using ANCOVA with treatment group and trial site asfactors and age as a covariate. Although not statistically significant,there was a trend towards the Formulation A group in pain intensitynormalized AUC over 0-72 hours. The LS means were 5.33 for theFormulation A group and 5.97 for the placebo group. The pain scores inthe Formulation A group were consistently lower than in the placebogroup the mean difference between the groups being most prominent in thefirst 24 hours (Table 14.1 below).

TABLE 14.1 Pain Intensity Normalized AUC over Scheduled Assessments byTreatment (MITT Subjects Set) Difference in Formulation A Placebo Means(Active- Least-Squares Means¹ (n = 40) (n = 20) Placebo)  AUC 0-24 hours5.56 6.38 −0.81  AUC 0-36 hours 5.72 6.38 −0.66  AUC 0-48 hours 5.626.30 −0.67  AUC 0-72 hours 5.33 5.97 −0.64  AUC 0-96 hours 5.07 5.62−0.55 AUC 0-last hours 4.04 4.27 −0.23 AUC 24-48 hours 5.59 6.27 −0.68AUC 36-72 hours 4.77 5.34 −0.57 AUC 48-72 hours 4.72 5.27 −0.55 AUC72-96 hours 4.31 4.62 −0.31 ¹Least-Squares Means estimated using anANOVA model with treatment group and study site as factors

Cumulative IV Morphine-Equivalent Dose Over 0-72 Hours Post-Dose

Opioid rescue analgesia cumulative IV morphine equivalent dose ispresented by treatment in Table 14.2 below. Cumulative morphineequivalent dose over 0-72 hours was compared between treatment groupsusing ANCOVA with treatment group and trial site as factors and age as acovariate. Although not statistically significant, there was a trendtowards the 5.0 mL Formulation A group in cumulative IV morphineequivalent dose over 0-72 hours. The LS mean were 44.27 for the 5.0 mLFormulation A group and 54.51 for the placebo group.

TABLE 14.2 Opioid Rescue Analgesia Cumulative IV Morphine EquivalentDose (mg) by Treatment (MITT Subjects Set) Difference Formulation APlacebo in Means Least-Squares Means¹ (n = 40) (n = 20) (Active-Placebo)Day 0-Day 2 (0-48 Hours) 36.47 47.21 −10.74 Day 0-Day 3 (0-72 Hours)44.27 54.51 −10.25 Day 0-Day 14 69.13 77.91 −8.77  0-24 Hours 24.1935.37 −11.18 24-48 Hours 12.35 12.51 −0.16 48-72 Hours 7.77 7.60 0.17¹Least-Squares Means estimated using an ANOVA model with treatment groupand study site as factors

For the secondary study endpoints, pain intensity on movement normalizedAUC (0-48 hours), mean total IV morphine equivalent opioid dose (0-48hours) and time to first opioid dose, was observed between the twotreatment groups. There was a trend towards the 5.0 mL Formulation Agroup in pain intensity normalized AUC over 0-48 hours. The cumulativemorphine equivalent dose over 0-24 hours, 0-48 hours, Days 0-14, and24-48 hours showed a trend towards the 5.0 mL Formulation A group forall timepoints.

Pain Intensity on Movement

Analyses were performed for pain intensity normalized AUC over 0-48hours, 0-last hours, 0-24 hours, 0-36 hours, 0-96 hours, 24-48 hours,36-72 hours, 48-72 hours and 72-96 hours. Pain intensity normalized AUCwas compared between treatment groups using ANCOVA with treatment groupand trial site as factors and age as a covariate (FIG. 18). Although notstatistically significant, there is a trend towards the 5.0 mLFormulation A group in pain intensity normalized AUC for all timepoints. For the MITT Subjects Set, at all time points, the LS means werelower for the 5.0 mL Formulation A group than the placebo group. FIG.19A depicts the mean pain intensity on movement by subjects in the MITTset administered Formulation A as compared to subjects administeredplacebo at time points post dose. FIG. 19B depicts the mean painintensity on movement by subjects in the PP set administered FormulationA as compared to subjects administered placebo at time points post dose.

Cumulative Morphine Equivalent Dose

Analyses were performed for cumulative morphine equivalent dose over0-48 hours, Days 0-14, 0-24 hours, 24-48 hours and 48-72 hours.Cumulative morphine equivalent dose was compared between treatmentgroups using ANCOVA with treatment group and trial site as factors andage as a covariate (FIG. 20). Although not statistically significant,there was a trend towards the 5.0 mL Formulation A group in cumulativemorphine equivalent dose for all time points.

For the MITT Subjects Set, apart from 48-72 hours, at all other timepoints, the LS means were lower for the 5.0 mL Formulation A group thanthe placebo group. For the PP Subjects Set, the LS means were lower forthe 5.0 mL Formulation A group than the placebo group for 0-72 hours,0-48 hours and 0-24 hours.

Time to First Opioid Use

Time to first opioid use was analyzed using a log-rank test to comparethe two treatment groups. The median time to first opioid use for theMITT Subjects Set (0.43 hours for Formulation A 5.0 mL compared to 0.48hours for placebo) and the PP Subjects Set (0.42 hours for Formulation A5.0 mL compared to 0.50 hours for placebo) was not statisticallysignificant. FIG. 21 depicts the cumulative morphine equivalent dose inthe MITT set administered Formulation A as compared to subjectsadministered placebo at time points post dose.

Efficacy Conclusions

For the primary study endpoints, although statistically significanttreatment effects were not seen in this study, there were indications ofreduction of pain scores and opioid use in the 5.0 mL Formulation Agroup compared to placebo. The LS mean pain intensity on movement AUCover 0 to 72 hours post-dose was 5.33 in the 5.0 mL Formulation A groupcompared to 5.97 for placebo. This difference was lower than theestimated value used in the sample size calculation (an observed meandifference of 0.64 compared to an estimated mean of 1.9). Theinferential aspects of the statistical analysis however, were not ofprimary importance in this study as the study was intended to be of anexploratory nature. The difference in cumulative morphine equivalentdose between the treatment groups was not statistically significant. LSmean cumulative morphine equivalent dose over 0 to 72 hours was 44.27 inthe 5.0 mL Formulation A group compared to 54.51 in the placebo group.For both primary endpoints, the differences compared to placebo weremost prominent during the first 6-10 hours post-surgery.

For the secondary study endpoints, pain intensity on movement normalizedAUC (0-48 hours), mean total morphine equivalent opioid dose (0-48hours) and time to first opioid dose, no statistically significantdifferences were observed between the two treatment groups. There was atrend towards the 5.0 mL Formulation A group in pain intensitynormalized AUC over 0-48 hours. The cumulative morphine equivalent doseover 0-24 hours, 0-48 hours, Days 0-14, 24-48 hours and 48-72 hours werenot statistically significant, although there was a trend towards the5.0 mL Formulation A group for all timepoints. The median time to firstopioid use was not statistically significant.

Safety Results:

All 60 subjects received at least part of their allocated treatment andwere included in the safety analysis. Equal proportions of subjectsexperienced at least one AE—38 (95.0%) subjects in the 5.0 mLFormulation A group and 19 (95.0%) subjects in the placebo group.Seventeen (42.5%) subjects in the 5.0 mL Formulation A group experiencedat least one AE with a maximum relationship of related, compared withseven (35.0%) subjects in the placebo group. Most AEs were either mildor moderate in intensity. Eight (20.0%) subjects in the 5.0 mLFormulation A group experienced at least one AE with a maximum severityof severe, compared with 5 (25.0%) subjects in the placebo group. Theseverity of TEAEs reported was similar between the two treatment groups.The most common AEs in the 5.0 mL Formulation A group were constipation,nausea, vomiting, dizziness, paranesthesia and somnolence. In theplacebo group, the most common AEs were constipation, nausea, dizzinessand somnolence. In general, the TEAEs expressed with high frequency weresimilar between the two treatment groups. There were no statisticallysignificant differences or trends in frequency of opioid related TEAEs(constipation, dizziness, drowsiness, nausea, respiratory depression,urinary retention, or vomiting) at any time point in the study. Only oneSAE was reported during the study. The event was pyrexia and wasreported by subject 03-007 in the 5.0 mL Formulation A group. The eventwas considered to be mild and unlikely to be related to study drug.Administration of 5.0 mL Formulation A was safe and well tolerated basedon review of hematology, biochemistry and urinalysis data, vital signassessment, and evaluation of physical examination findings andconcomitant medication use. All subjects had surgical site healing andlocal tissue condition at Day 14 as expected. TEAEs by system, organ,class and preferred term are summarized by system organ class in Table14.3 below.

TABLE 14.3 TEAEs by System, Organ, Class 5 mL Formulation A Placebo (N =40) (N = 20) System Organ Class n % n % Number of subjects with at leastone TEAE 38 (95.0) 19 (95.0) Ear And Labyrinth Disorders  8 (20.0)  1(5.0) Eye Disorders  1 (2.5)  0 (0.0) Gastrointestinal Disorders 32(80.0) 17 (85.0) General Disorders And  7 (17.5)  2 (10.0)Administration Site Conditions Infections And Infestations  1 (2.5)  1(5.0) Injury, Poisoning And Procedural  6 (15.0)  2 (10.0) ComplicationsInvestigations  4 (10.0)  2 (10.0) Metabolism And Nutrition Disorders  0(0.0)  1 (5.0) Musculoskeletal And Connective  6 (15.0)  1 (5.0) TissueDisorders Nervous System Disorders 33 (82.5) 18 (90.0) PsychiatricDisorders  1 (2.5)  1 (5.0) Renal And Urinary Disorders  9 (22.5)  4(20.0) Reproductive System And Breast Disorders  1 (2.5)  0 (0.0)Respiratory, Thoracic And Mediastinal  7 (17.5)  2 (10.0) Disorders SkinAnd Subcutaneous Tissue Disorders  8 (20.0)  2 (10.0)

A summary of TEAEs experienced by >7.5% of subjects, by preferred termand treatment group is presented in Table 14.4 below. 7.5% was selectedto review frequency of TEAEs as this included TEAEs experienced by atleast two subjects in the smaller treatment group. The most common AEsin the 5.0 mL Formulation A group were constipation, nausea, vomiting,dizziness, paranesthesia and somnolence. In the placebo group, the mostcommon AEs were constipation, nausea, dizziness and somnolence. Ingeneral, the TEAEs expressed with high frequency were similar betweenthe two treatment groups.

TABLE 14.4 TEAEs with Frequency > 7.5% by Treatment Group 5 mLFormulation A Placebo (N = 40) (N = 20) Preferred Term n % n %Somnolence 29 (72.5) 16 (80.0) Nausea 26 (65.0) 15 (75.0) Constipation18 (45.0) 10 (50.0) Vomiting 14 (35.0)  4 (20.0) Dizziness 14 (35.0)  7(35.0) Paraesthesia  9 (22.5)  2 (10.0) Dysuria  8 (20.0)  4 (20.0)Pruritus  8 (20.0)  2 (10.0) Hypoaesthesia  7 (17.5)  3 (15.0) Tinnitus 6 (15.0)  1 (5.0) Dysgeusia  5 (12.5)  1 (5.0) Headache  5 (12.5)  4(20.0) Dry Mouth  4 (10.0)  2 (10.0) Pyrexia  4 (10.0)  1 (5.0) MuscleTwitching  3 (7.5)  0 (0.0) Dyspnoea  3 (7.5)  0 (0.0) PharyngolaryngealPain  3 (7.5)  1 (5.0)

Conclusion

The efficacy data in this study showed a consistent reduction of painscores (as measured by mean pain intensity on movement AUC, timenormalized under the curve, during the period 0 to 72 hourspost-surgery) in subjects randomized to receive 5.0 mL Formulation Acompared to placebo. There was also a reduction of opioid use (asmeasured by the amount of opioids taken in the three days post-surgery)in subjects randomized to receive 5.0 mL Formulation A compared toplacebo. These reductions were not statistically significant. Thefindings related to pain scores and opioid use were most prominentduring the first 6-10 hours post-surgery. The incidence of AEs, vitalsigns and laboratory abnormalities indicate that administration of 5.0mL Formulation A is safe, and the lack of withdrawals and mild nature ofAEs indicate that administration of 5.0 mL Formulation A is welltolerated in this patient population.

Example 15

A clinical trial was conducted to study the administration of abupivacaine composition into the subacromial space in patientsundergoing arthroscopic subacromial decompression. The study furtherinvestigated systemic and local safety of the bupivacaine composition ascompared to placebo in patients.

The bupivacaine composition (Formulation A) used in these studies is aclear, light yellow to brown liquid, intended for use as a postsurgicalanalgesic after a variety of surgical procedures. The bupivacainecomposition contains bupivacaine base in a sustained-release matrixcomprised of a fully esterified sugar derivative. In this study, theintent of Formulation A is to provide effective postoperative localanalgesia by providing sustained local release of bupivacaine over aperiod of several days. The formulation includes 3 components (sucroseacetate isobutyrate 66 wt %, benzyl alcohol 22.0 wt %, and bupivacainebase 12.0 wt %) that are administered together as a sterile solution.

Composition: Formulation A Active ingredient: Bupivacaine base Inactiveingredients: Sucrose acetate isobutyrate, benzyl alcohol Administration:Varied, based on surgical procedure, interstitial (FDA Code 088) eitherby tissue infiltration, injection or needle-free deposition for generalsurgical applications. Strength: 132 mg/mL, 660 mg bupivacaineComposition Placebo Active ingredient: Not applicable Inactiveingredients: Sucrose acetate isobytyrate, benzyl alcohol Administration:Varied, based on surgical procedure, interstitial (FDA Code 088) eitherby tissue infiltration, injection or needle-free deposition for generalsurgical applications.

Objectives

Primary objective—To determine the efficacy of Formulation A(bupivacaine, benzyl alcohol, sucrose acetate isobutyrate) administeredsubcutaneously or into the subacromial space in subjects undergoingelective arthroscopic shoulder surgery involving subacromialdecompression.

Secondary objective—To determine the safety and tolerability ofFormulation A (bupivacaine, benzyl alcohol, sucrose acetate isobutyrate)administered subcutaneously or into the subacromial space in subjectsundergoing arthroscopic shoulder surgery involving subacromialdecompression.

Study objectives were defined specifically for each of Cohort 1 andCohort 2.

Methods

The study was a randomized, double-blind, placebo-controlled study ofthe efficacy and safety of subcutaneous or subacromial bupivacaine inpatients undergoing rotator cuff repair and to assess the safety andtolerability of Formulation A (bupivacaine, benzyl alcohol, sucroseacetate isobutyrate) as a delivery system. Surgery in all subjects wasperformed under local or general anesthesia according to standard localpractice.

The study was conducted in 2 separate and sequential cohorts (Cohort 1and Cohort 2). Approximately equal numbers of subjects were to beenrolled, in sequence, to each cohort. The study duration was up to 21days including screening, admission to clinic and surgery (Day 0),postoperative evaluations, discharge from clinic, and follow-up throughDay 14.

The subjects were evaluated on Days 1 and 2 in the clinic or at home, onDay 3 in the clinic, and on Days 4 through 7 by telephone followingsurgery and treatment. Subjects returned on Day 14 for follow-upevaluation and plasma collection. Subjects recorded pain intensity (PI),concomitant medications, adverse events (AEs), and rescue analgesia ondiary cards from Day 0 through Day 7. Subjects also recorded AEs andconcomitant medications through Day 14.

Cohort 1:

Immediately prior to surgery 45 subjects were randomly assigned in a1:1:1 ratio (Treatment Group 1, Treatment Group 2, Treatment Group 3) toreceive 1 of the following treatments:

Treatment Group 1: Prior to wound closure, 5.0 mL of placebo compositionwas injected into the subacromial space. After wound closure, a totalvolume of 5.0 mL of Formulation A was administered as 2 trailingsubcutaneous injections along each side of the incision line. The totalamount of bupivacaine was 660 mg.

Treatment Group 2: Prior to wound closure, 5.0 mL of Formulation A wasinjected into the subacromial space. After wound closure, a total volumeof 5.0 mL of placebo composition was administered as 2 trailingsubcutaneous injections along each side of the incision line. The totalamount of bupivacaine was 660 mg.

Treatment Group 3: Prior to wound closure, 5.0 mL of placebo compositionwas injected into the subacromial space. After wound closure, a totalvolume of 5.0 mL of placebo composition was administered as 2 trailingsubcutaneous injections along each side of the incision line. (The totaldelivered volume of placebo composition was 10.0 mL.) For all treatmentgroups if the procedure was performed arthroscopically, the subcutaneousdoses of study drug were administered evenly around all arthroscopicportals.

Cohort 2:

Upon completion of Cohort 1, enrollment of subjects into Cohort 2 wasstarted. Immediately prior to surgery, 45 subjects were randomlyassigned in a 1:1 enrollment ratio (Treatment Group 4 and TreatmentGroup 5) to receive 1 of the following treatments:

Treatment Group 4: During wound closure, 5.0 mL of placebo compositionwas injected into the subacromial space.

Treatment Group 5: During wound closure, 5.0 mL of Formulation A wasinjected into the subacromial space

During the study, the amount of drug to be administered in Cohort 2 waschanged from 7.5 mL (990 mg bupivacaine) to 5.0 mL (660 mg bupivacaine).However, 4 subjects were administered Treatment 4a (7.5 mL placebocomposition) and 3 subjects were administered Treatment 5a (7.5 mLFormulation A)

Nine subjects were randomized to receive placebo composition or 5.0 mLFormulation A at 1 participating center in order to obtain PK(pharmacokinetic) measurements in the double-blind portion of the study.Of these 9 subjects, 4 received 5.0 mL Formulation A and 5 receivedplacebo composition. Upon completion of the double-blind portion of thestudy, a supplemental PK sub-study protocol was implemented to enroll upto 14 additional PK subjects to receive 5.0 mL open-label Formulation Asubacromially. The overall PK results for the 18 PK subjects whoreceived 5.0 mL Formulation A is discussed in greater detail below.

Preparation of Study Drug for Administration:

The study drug was administered with 5 mL syringes which were used towithdraw 5.0 mL of study drug from 10.0 mL vials of either Formulation Aor Placebo Composition.

Postoperative Rescue Analgesia

Postoperative rescue analgesia was to be prescribed on request. Thetime, name, and dose of all rescue analgesics were recorded throughoutthe study period by all subjects on either paper or electronic diaries.Distinction was made between those analgesics taken for surgical woundpain and those taken for other indications. A pain intensity (PI)evaluation was completed immediately prior to each time rescue analgesicmedication was requested by a subject.

Subject CRITERIA

Number of subjects: The planned enrollment was 90 subjects in order toensure at least 72 evaluable subjects (approximately 36 subjects in eachcohort, 12 subjects in each treatment group of Cohort 1 and 18 in eachtreatment group of Cohort 2). A total of 40 subjects were enrolled inCohort 1; 14 to Treatment 1, 10 to Treatment 2, and 16 to Treatment 3.All 40 subjects completed Cohort 1. A total of 52 subjects were enrolledin Cohort 2; 4 to Treatment 4a, 24 to Treatment 4, 3 to Treatment 5a,and 21 to Treatment 5. Fifty subjects completed Cohort 2; 1 subject inTreatment 4 and 1 subject in Treatment 5a voluntarily withdrew.

Upon completion of the double-blind portion of the study, a supplementalPK sub-study protocol was implemented which enrolled 14 additional PKsubjects to receive 5.0 mL open-label Formulation A subacromially.

Diagnosis and main criteria for inclusion: Males and females, 18 yearsof age and older who underwent elective rotator cuff repair, were ingood general health, and met all the inclusion and exclusion criteria,were eligible to participate in the study.

Duration of treatment: Subjects received a single dose of study drug.The study duration was up to 21 days comprising screening, admission toclinic and surgery (Day 0), postoperative evaluations, discharge fromclinic, and follow-up through Day 14.

Criteria for Evaluation:

Efficacy:

Efficacy was assessed using the subjects' self-evaluation of PI and paincontrol collected on subject diaries (Days 0 to 7), the Modified BriefPain Inventory (Days 1 to 7), and the subjects' use of concomitantrescue analgesic medication (Days 0 to 14).

The primary efficacy endpoints were PI on movement, PI at rest, and paincontrol poor(1), fair(2), good(3), very good(4), excellent(5) collectedon Days 0 through Day 7. The secondary efficacy endpoints were worst andleast pain scores, rescue analgesia usage, function, overall treatmentsatisfaction, and individual PI over time.

Safety:

Safety evaluations included AEs; assessments of laboratory tests such aschemistry, hematology, and urinalysis; a serum pregnancy test (ifapplicable); periodic monitoring of vital signs; 12 leadelectrocardiogram (ECG); concomitant medications; and physicalexaminations. Evaluations also included surgical site healing and localtissue conditions

Statistical Methods:

Unless otherwise stated, all statistical tests were performed using2-sided tests at the 5% significance level. No multiplicity adjustmentwas made for any of the analyses. The per-protocol (PP) populationincludes all subjects who successfully underwent the surgical procedure,received study drug, and had postoperative data on pain evaluationsrecorded at 1 or more postoperative time points. Summary tables andstatistical analysis of all efficacy endpoints are based on the PPpopulation. Safety summaries are based on the safety population, whichincludes all randomized subjects who received any amount of study drug.

Data was determined for the following treatment groups:

-   -   Treatment 1 (Formulation A subcutaneous)    -   Treatment 2 (Formulation A subacromial)    -   Treatment 5 (Formulation A subacromial)    -   Formulation A (Treatments 2 and 5)    -   Treatment 5a (7.5 mL Formulation A)    -   Pooled Placebo comprising:        -   Treatment 3 (10.0 mL placebo composition)        -   Treatment 4 (5.0 mL placebo composition)        -   Treatment 4a (7.5 mL placebo composition)

The comparison of primary interest was between Treatment 5 and PooledPlacebo. The significance of comparisons between Formulation A,Treatment 2, and Treatment 1 and Pooled Placebo were also determined.

The incidence (number and percentage) of treatment-emergent AEs wasdetermined for each treatment group in accordance with the MedicalDictionary for Regulatory Activities (MedDRA) Version 8.0 system organclass and preferred term. A separate overall incidence was determined onAEs with onset on Day 0. The worst severity of the AEs and theirrelationship to study medication was also determined.

Separate overall incidence summaries were determined for anticipatedevents as checked on subject diaries: nausea/vomiting, drowsiness,itching, constipation, dizziness, tinnitus, dysgeusia, and paresthesia.

Specific safety evaluations of the Modified Brief Pain Inventory weretabulated by study day and treatment. Incidence across all study dayswas also determined by treatment.

Surgical site healing and local tissue condition evaluations weresummarized and tabulated by subject incidence (number and percentage)for each treatment group over time.

Abnormal or change from screening physical examination results weredetermined. Vital signs were listed descriptively for each treatmentgroup at each collection time point. Changes from baseline (predose)vital signs were summarized for each treatment and scheduled interval.Screening and unscheduled ECGs were used.

Results

Efficacy Results:

The primary endpoint PI scores (AUC/120 hours) during movement and atrest are summarized by treatment group in Table 15.1 and Table 15.2respectively. Mean PI_(move) values in the Formulation A treatmentgroups were 5.47, 3.27, and 5.12 (Treatments 1, 2, and 5, respectively),compared to 5.22 in the Pooled placebo group. Treatment 2 had the lowestmean value (least pain). The comparison to the Pooled Placebo groupdemonstrates that Treatment 2 was significantly better than PooledPlacebo (treatment difference=−1.95, 95% CI=−3.59 to −0.31, P=0.02). TheFormulation A group was numerically better than Pooled placebo(treatment difference=−1.03, 95% CI=−2.14 to 0.09); this difference didnot reach statistical significance (P=0.072). For average PI duringrest, Treatment 2, Treatment 5, and Formulation A were numericallybetter than Pooled placebo; these differences did not reach statisticalsignificance.

TABLE 15.1 Summary of Pain Intensity During Movement Time-weightedAverage Scores (AUC/120), PP Population Comparison to Pooled PlaceboTreatment n Mean (SD) Mean Difference (95% CI) P-value Treatment 1 145.47 (2.352) 0.25 (−1.13-1.62) 0.720 Treatment 2 9 3.27 (1.648) −1.95(−3.59-−0.31) 0.020 Treatment 5 21 5.12 (2.230) −0.10 (−1.29-1.09) 0.866Formulation A 30 4.56 (2.219) −1.03 (−2.14-0.09) 0.072 Pooled Placebo 445.22 (2.281) Treatments (5.0 mL): 1 = Formulation A Subcutaneous 2 =Formulation A Subacromial 3 = Placebo 4 = Placebo 5 = Formulation ATreatments 4a and 5a are the same as Treatments 4 and 5, but using 7.5mL Formulation A = Treatments 2 and 5 Pooled placebo = Treatments 3, 4a,and 4

TABLE 15.2 Summary of Pain Intensity During Rest Time-weighted AverageScores (AUC/120), PP Population Comparison to Pooled Placebo Treatment nMean (SD) Mean Difference (95% CI) P-value Treatment 1 14 3.53 (2.331)0.43 (−0.76-1.63) 0.473 Treatment 2 9 2.16 (1.496) −0.95 (−2.37-0.48)0.190 Treatment 5 21 2.58 (1.674) −0.52 (−1.56-0.51) 0.315 Formulation A30 2.45 (1.609) −0.73 (−1.71-0.24) 0.136 Pooled Placebo 44 3.10 (1.995)Treatments (5.0 mL): 1 = Formulation A Subcutaneous 2 = Formulation ASubacromial 3 = Placebo 4 = Placebo 5 = Formulation A Treatments 4a and5a are the same as Treatments 4 and 5, but using 7.5 mL Formulation A =Treatments 2 and 5 Pooled placebo = Treatments 3, 4a, and 4The other primary efficacy variable was pain control by study day andtreatment, assessed using the numerical score for the PP Population(1=Poor, 5=Excellent). The average pain control scores for Day 1 throughDay 7 are summarized by treatment group in Table 15.3 Statisticalcomparisons were limited to the Formulation A versus Pooled placebo. Theonly statistically significant difference observed was on Day 1(P=0.008) where the Formulation A and Pooled placebo treatment groupshad average pain control scores of 3.3 and 2.5, respectively; nostatistically significant differences were observed during the rest ofthe study (Days 2 through 7) for pain control.

TABLE 15.3 Pain Control on Study Days 1 through 7 by Treatment, PPPopulation Mean Pain Control by Day Treatment Group Day 1 Day 2 Day 3Day 4 Day 5 Day 6 Day 7 Treatment 1 3.0 2.7 3.1 3.0 3.2 3.1 3.1Treatment 2 3.3 3.4 3.2 3.4 3.4 3.7 3.8 Treatment 5 3.3 3.4 3.4 3.7 3.63.6 3.7 Formulation A 3.3 3.4 3.3 3.6 3.5 3.6 3.7 Pooled Placebo 2.5 3.03.4 3.4 3.4 3.4 3.6 P-value (Formulation 0.008 0.111 0.767 0.532 0.6080.380 0.689 A vs. Pooled Placebo) Treatments (5.0 mL): 1 = Formulation ASubcutaneous 2 = Formulation A Subacromial 3 = Placebo 4 = Placebo 5 =Formulation A Treatments 4a and 5a are the same as Treatments 4 and 5,but using 7.5 mL Formulation A = Treatments 2 and 5 Pooled placebo =Treatments 3, 4a, and 4

The opioid rescue medication, expressed as cumulative IV morphineequivalent doses are summarized in Table 15.4 for Days 0 to 5. Meanvalues in Formulation A treatment groups for opioid rescue analgesiacumulative morphine equivalent doses were 70.30, 24.96, and 42.74(Treatments 1, 2, and 5, respectively), compared to 55.27 in the Pooledplacebo group. Treatment 2 had the lowest mean value (least cumulativemorphine equivalent dose). Compared to the Pooled placebo group,Treatment 2 was numerically better than Pooled placebo; the differencedid not reach statistical significance (P=0.147).

TABLE 15.4 Opioid Rescue Analgesia Cumulative (Day 0 through 5) IVMorphine Equivalent Dose (unit/unit) by Treatment, PP PopulationComparison to Pooled Placebo Treatment n Mean (SD) P-Value Treatment 114 70.30 (62.984) 0.389 Treatment 2 9 24.96 (20.175) 0.147 Treatment 521 50.36 (66.102) 0.744 Formulation A 30 42.74 (57.148) 0.216 PooledPlacebo 44 55.27 (55.509) Treatments (5.0 mL): 1 = Formulation ASubcutaneous 2 = Formulation A Subacromial 3 = Placebo 4 = Placebo 5 =Formulation A Treatments 4a and 5a are the same as Treatments 4 and 5,but using 7.5 mL Formulation A = Treatments 2 and 5 Pooled placebo =Treatments 3, 4a, and 4

In Formulation A treatment groups (Treatments 1, 2, and 5), as well asin the Pooled placebo group, all subjects required rescue analgesia.

All of the other secondary endpoints (worst and least pain scores,function, overall treatment satisfaction, and individual PI over timedid not show any significant results.

A post hoc analysis of PI over time was conducted for the 2 cohortsseparately. In Cohort 1, the Formulation A subacromial treatment group(Treatment 2) had a lower PI on movement compared with the placebo group(Treatment 3) and no difference was observed between the Formulation Asubcutaneous treatment group (Treatment 1) and the placebo group(Treatment 3). In Cohort 2, no reduction in PI on movement was observedin the Formulation A subacromial treatment group (Treatment 5) versusplacebo (Treatment 4). No differences in opioid rescue analgesia usewere observed between the treatment groups in Cohort 1 and Cohort 2.

FIG. 22 shows mean PI_(move) over time, analyzed separately for Cohort 1and Cohort 2. This Figure demonstrates that for Cohort 1, the average PIon movement score for Treatment 2 (5.0 mL Formulation A subacromial) waslower than the average PI on movement score for placebo (Treatment 3).No difference in PI on movement scores between Treatment 1 (5.0 mLFormulation A subcutaneous) and placebo (Treatment 3) was observed. InCohort 2, no reduction in PI on movement in Treatment 4 (Formulation Asubacromial) versus placebo (Treatment 5) was observed.

A subgroup analysis was performed on subjects from both cohorts who hadminimal or no glenohumeral pathology. The difference between the pooledsubacromial active treatment groups and the pooled placebo was testedusing the pre-specified ANOVA model including study center and treatmentgroup as factors. The mean pain intensity on movement AUC (over the72-hour period) for active and placebo were 3.6 and 6.1, respectively.The corresponding difference in mean pain intensity on movement AUC(over the 72-hour period, active-placebo) was −2.6 (95% CI:(−4.1,−1.1)). This result is statistically significant (p=0.0012), andsupports analgesic benefit in favor of active subacromial treatmentrepresenting a 41.8% reduction in pain (while the ITT analysis showed16.5% reduction).

FIG. 23 shows PI_(move) over time in the subgroup of subjects who hadminimal or no glenohumeral pathology. It demonstrates increasedanalgesia in those treatment groups using subacromial administration ofFormulation A (Treatments 2 and 5) compared to placebo (Treatments 3 and4). Treatment 1, which used subcutaneous administration of FormulationA, did not show a reduction in PI_(move) compared to placebo (Treatments3 and 4).

The mean total morphine-equivalent dose for active and placebo were 33.5and 56.9, respectively. The corresponding difference in means between(placebo-active) was 23.4 (95% CI: (−1.1, 47.9)). This result representsa 41.1% reduction in opioid use (while the ITT analysis showed a 16.1%)in favor of active subacromial treatment, but was not statisticallysignificant.

Safety Results:

The overall frequency of AEs was similar between treatment groups. Themost commonly reported treatment-emergent AEs were nausea, somnolence,pruritus, and constipation. The majority of treatment-emergent AEs wereof mild or moderate severity. There were no deaths or discontinuationsdue to AEs. One serious AE occurred in treatment group 4 (postproceduralpain), which was severe in intensity and considered unrelated to studydrug by the investigator. An analysis of specific safety evaluations ofinterest did not indicate any opioid-related safety issues.

A summary of treatment-emergent adverse events (TEAE) by treatment isshown in Table 15.5.

TABLE 15.5 Specific Safety Evaluations Observed Over Days 0 to 7 (SafetyPopulation) Pooled Treatment 1 Treatment 2 Treatment 5 Treatment 5aFormulation A Placebo (n = 14) (n = 10) (n = 21) (n = 3) (n = 31) (n =44) Nausea 11 (78.6%) 7 (70.0%) 14 (66.7%) 3 (100.0%) 20 (64.5%) 34(77.3%) Vomiting  5 (35.7%) 3 (30.0%)  5 (23.8%) 2 (66.7%)  7 (22.6%) 15(34.1%) Somnolence  8 (57.1%) 9 (90.0%) 12 (57.1%) 3 (100.0%) 20 (64.5%)33 (75.0%) Dizziness 10 (71.4%) 5 (50.0%) 11 (52.4%) 3 (100.0%) 15(48.4%) 22 (50.0%) Tinnitus  4 (28.6%) 2 (20.0%)  2 (9.5%) 1 (33.3%)  3(9.7%)  7 (15.9%) Pruritus 10 (71.4%) 8 (80.0%) 12 (57.1%) 3 (100.0%) 19(61.3%) 29 (65.9%) Dysgeusia  6 (42.9%) 3 (30.0%)  6 (28.6%) 1 (33.3%) 8 (25.8%) 13 (29.5%) Paresthesia  5 (35.7%) 2 (20.0%)  4 (19.0%) 2(66.7%)  5 (16.1%) 12 (27.3%) Constipation 10 (71.4%) 5 (50.0%) 12(57.1%) 3 (100.0%) 16 (51.6%) 24 (54.5%) Treatments (5.0 mL): 1 =Formulation A Subcutaneous 2 = Formulation A Subacromial 3 = placebo 4 =placebo 5 = Formulation A Treatments 4a and 5a are the same asTreatments 4 and 5, but using 7.5 mL Formulation A = Treatments 2 and 5Pooled Placebo = Treatments 3, 4a, and 4

Conclusions

Formulation A is an injectable solution specifically formulated toprolong regional postoperative analgesia and is intended for use as apostoperative analgesic after a variety of surgical procedures. Eachmilliliter of Formulation A contains 12% wt bupivacaine representing 132mg/mL of bupivacaine. The primary efficacy endpoint of PI move was shownto be significantly better in Treatment 2 (Formulation A Subacromial)compared to the Pooled placebo group (Treatments 3, 4a, and 4), and wasnot significantly better in Treatment 1 (Formulation A Subcutaneous),Treatment 5 (Formulation A), and Formulation A (Treatments 2 and 5,Formulation A Subacromial and Formulation A, respectively) compared tothe Pooled placebo group (Treatments 3, 4a and 4). The results of thepost hoc analyses in Cohort 1 showed that the Formulation A subacromialtreatment group (Treatment 2) had a lower PI on movement compared withthe placebo group (Treatment 3) and no difference was observed betweenFormulation A subcutaneous treatment group (Treatment 1) and the placebogroup (Treatment 3). In the subanalysis performed on subjects from bothcohorts who had minimal or no glenohumeral pathology, those treatmentgroups using subacromial administration of Formulation A (Treatments 2and 5) had a lower PI on movement compared to placebo (Treatments 3 and4). Treatment 1, which used subcutaneous administration of FormulationA, did not show a reduction in PI on movement compared to placebo. Theoverall frequency of AEs was similar between treatment groups.

Example 16

A randomized, parallel-group, double-blind, saline placebo-controlledand bupivacaine HCl active-controlled clinical trial evaluating thesafety and efficacy of 5 mL of Formulation A in subjects undergoingelective outpatient laparoscopic cholecystectomy was conducted. In thisstudy, Formulation A was prepared as described above and includes 3components (sucrose acetate isobutyrate 66 wt %, benzyl alcohol 22.0 wt%, and bupivacaine base 12.0 wt %) that are administered together as asterile solution.

Methods

The trial included: 1) a randomized, parallel-group, double-blind,placebo-controlled study (Part 1) and a randomized, parallel-group,double-blind, bupivacaine HCl active-controlled study (Part 2). Thetrial evaluated the efficacy and safety of Formulation A (bupivacaine,benzyl alcohol, sucrose acetate isobutyrate) as a delivery system insubjects undergoing elective outpatient laparoscopic cholecystectomy.

In Part 1, subjects were randomized in a nominal 1:1 ratio to receive 1of 2 treatments, Formulation A or saline placebo. In Part 2, subjectswere randomized in a 1:1 ratio to receive 1 of 2 treatments, FormulationA or bupivacaine HCl.

The study was conducted as 2 separate parts (Part 1 and Part 2). Forpart 1, 92 subjects were randomized and treated by instilling either 5mL of Formulation A or saline placebo with a blunt-tipped applicatordirectly into the laparoscopic port incisions at the close of surgery.For part 2, subjects were randomized in a 1:1 ratio to receive 5 mL ofFormulation A instilled with a blunt-tipped applicator directly into thelaparoscopic port incisions or 15 mL (75 mg) bupivacaine HCl 0.5%infiltrated with a 22 gauge needle into the margins of the portincisions.

Subjects underwent surgery on Day 1, during which they were administereda single dose of Formulation A, placebo or bupivacaine HCl at the closeof surgery while still anesthetized.

All subjects had access to adequate pain relief through the use ofrescue medication. While in the post-anesthesia care unit (PACU),subjects were administered IV fentanyl 12.5-25 μg upon request forbreakthrough pain. Upon discharge, subjects were provided withacetaminophen 500 mg tablets for mild-to-moderate pain and aprescription for oxycodone 5 mg immediate-release tablets formoderate-to-severe pain. Subjects self-administered these medications onan as-needed basis according to written dosing instructions provided bythe site investigator or study staff.

Subjects were issued an electronic diary (LogPad) to record thespecified data after surgery.

In part 1 of the study 92 patients in total were administeredFormulation A or saline placebo. 45 patients were administered 5 mL ofFormulation A and 47 patients received the placebo. For part 2 of thestudy, 296 patients were treated with Formulation A or active control,bupivacaine HCl. 148 patients were administered 5 mL of Formulation Aand 148 patients received active control bupivacaine HCl.

Formulation a, Dose and Mode of Administration:

In Part 1 and Part 2, subjects randomized to the test product wereadministered 5 mL Formulation A (132 mg/mL bupivacaine base, 660 mgtotal) by direct instillation into the surgical incisions. The 5 mL ofFormulation A was divided between the 4 ports according to aprotocol-specified dosing schedule, to provide coverage of all surgicalincisions. The fascia was closed, as required, prior to instillation ofFormulation A. Formulation A was instilled into the incisions via ablunt-tipped syringe-tip applicator just prior to skin closure. Afteradministration, the skin was closed in standard fashion withsubcuticular sutures and cyanoacrylate skin adhesive or Steri-Strips™.

ReferenceComparator, Dose and Mode of Administration:

Part 1:

In Part 1, subjects randomized to saline-placebo were administeredsterile normal saline 5 mL (0.9% sodium chloride injection, USP) bydirect instillation into the surgical incisions. The 5 mL of placebo wasdivided between the 4 ports according to a protocol-specified dosingschedule, to provide coverage of all surgical incisions. The fascia wasclosed, as required, prior to instillation of the placebo composition.The placebo composition was instilled into the incisions via ablunt-tipped syringe-tip applicator just prior to skin closure. Afteradministration, the skin was closed in standard fashion withsubcuticular sutures and cyanoacrylate skin adhesive or Steri-Strips™.

Part 2:

In Part 2, subjects randomized to active control were administeredbupivacaine HCl 0.5% 15 mL (75 mg; without epinephrine) by infiltrationinto the margins of the surgical incisions with a 22 gauge needle. The15 mL of bupivacaine HCl composition was divided between the 4 portsaccording to a protocol-specified dosing schedule, to provide coverageof all surgical incisions. The fascia was closed, as required, prior toadministration of the bupivacaine HCl active control composition. Afterinfiltration, the skin was closed in standard fashion with subcuticularsutures and cyanoacrylate skin adhesive or Steri-Strips™.

Efficacy Analyses Primary

The primary efficacy endpoints for Part 1 and Part 2 were as follows:

Part 1: Pain intensity on movement measured at scheduled time pointsfrom 0 to 72 hours following test drug administration, adjusted forprior rescue medication use and analyzed by a mixed effect ANOVA modelof repeated measures (MMRM).

Part 2: Pain intensity on movement measured at scheduled time pointsfrom 0 to 48 hours following test drug administration, adjusted forprior rescue medication use and analyzed by a mixed effect ANOVA modelof repeated measures (MMRM).

Results

Efficacy Results:

Primary Endpoint

The primary efficacy endpoint was pain intensity on movement measured atscheduled time points from 0-72 hours (Part 1) and 0-48 hours (Part 2)following administration of test composition, adjusted for prior rescuemedication use. For Part 1, the comparison was between Formulation A(Part 1 subjects only) and saline placebo, and for Part 2, thecomparison was between Formulation A (Part 2 subjects only) andbupivacaine HCl. Results of the primary endpoint analysis are summarizedin Table 16.1 below.

TABLE 16.1 Primary Outcomes by Study Part: Pain Intensity on Movementfrom 0 to 72 Hours Post-treatment (Part 1) and from 0 to 48 HoursPost-treatment (Part 2) Part 1 Part 2 Formulation A Saline PlaceboFormulation A Bupivacaine HCl (N = 46) (N = 46) (N = 148) (N = 148) Painintensity on movement 0 to 72 hours Mean (SE) 4.38 (0.091) 5.17 (0.107)95% CI (4.21, 4.56) (4.96, 5.38) Pain intensity on movement 0 to 48hours Mean (SE) 5.55 (0.065) 5.87 (0.059) 95% CI (5.42, 5.67) (5.76,5.99) Formulation A versus comparator ^([1]) LS Mean −0.785 (0.432)−0.371 (0.2412) Difference (SE) 95% CI (−1.631, 0.062) (−0.844, 0.101)p-value 0.0692 0.1235 CI = confidence interval; SE = standard error; LS= least squares; WOCF = worst observation carried forward

Safety Results:

There were no fatalities in this trial. Nine treated subjects (6Formulation A and 3 bupivacaine HCl) experienced treatment-emergentserious adverse events (SAE), all of which were considered unrelated tostudy drug administration. Table 16.2 summarizes the safety data.

TABLE 16.2 Overall Summary of Treatment Emergent Adverse Events (SafetyPopulation) Part 1 Part 2 Formulation Saline Formulation Bupivacaine APlacebo A HCl (N = 45 (N = 47) (N = 148) (N = 148) At Least One TEAE 43(95.6%) 47 (100%) 148 (100%) 146 (98.6%) At Least OneSpontaneously-reported 43 (95.6%) 45 (95.7%) 148 (100%) 138 (93.2%) TEAEAt Least One LogPad-Solicited TEAE 36 (80.0%) 39 (83.0%) 134 (90.5%) 132(89.2%) At Least One Serious TEAE 1 (2.2%) 0 (0.0%) 5 (3.4%) 3 (2.0%) AtLeast One TEAE Leading to Study 0 (0.0%) 0 (0.0%) 0 (0.0%) 1 (0.7%)Discontinuation Maximum Relationship to Study Drug  Related 32 (71.1%)26 (55.3%) 125 (84.5%) 104 (70.3%)  Not Related 11 (24.4%) 21 (44.7%) 23(15.5%) 42 (28.4%) Maximum Severity  Mild 13 (28.9%) 22 (46.8%) 83(56.1%) 92 (62.2%)  Moderate 23 (51.1%) 25 (53.2%) 55 (37.2%) 49 (33.1%) Severe 7 (15.6%) 0 (0.0%) 10 (6.8%) 5 (3.4%) At Least One Severe andRelated TEAE 5 (11.1%) 0 (0.0%) 0 (0.0%) 0 (0.0%) At Least One Seriousand Related TEAE 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) Fatal TEAE 0 (0.0%)0 (0.0%) 0 (0.0%) 0 (0.0%)

Example 17

A phase 3 international, multicenter, randomized, double-blind,parallel-group trial of 5 mL Formulation A (132 mg/mL, 660 mgbupivacaine) in patients undergoing a variety of general surgicalprocedures with various wound sizes was conducted.

Methods

The study was an international, multicenter, randomized, double-blind,parallel-group controlled trial evaluating the safety, efficacy,effectiveness, and pharmacokinetics (PK) of 5 mL of Formulation A inpatients undergoing a variety of general surgical procedures withvarious wound sizes. All surgical procedures were elective, non-urgent,and indicated for the conditions identified below.

Randomization was stratified by surgical procedure (cohort) and byclinical site. The cohorts were as follows:

Cohort 1: Laparotomy. Approximately 50 patients were randomized toreceive either 5 mL of Formulation A or Bupivacaine HCl 30 mL 0.5%solution in a 3:2 ratio, respectively. This cohort included patientsundergoing open laparotomy for resection of liver, small bowel, stomach,spleen, gall bladder, or colon.

Cohort 2: Laparoscopic cholecystectomy. Approximately 50 patients wererandomized to receive either 5 mL of Formulation A or Bupivacaine HCl 30mL 0.5% solution in a 3:2 ratio, respectively.

Cohort 3: Laparoscopically-assisted colectomy. Approximately 204patients were randomized to receive either 5 mL of Formulation A orvehicle-Placebo 5 mL in a 3:2 ratio, respectively. This cohort includedpatients undergoing laparoscopically-assisted colectomy without plannedformation or closure of stoma for colon cancer, diverticulitis, orpolyps. A pneumoperitoneal and an intracorporeal approach was used toexplore the abdomen, mobilize the colon, identify critical structures,and ligate the vascular pedicle for left-sided and sigmoid colectomies.

Active Control, Dose and Mode of Administration:

In the active comparator treatment groups (Cohorts 1 and 2); 30 mL ofBupivacaine HCl 0.5% solution (5 mg/mL, 150 mg bupivacaine) wasadministered by infiltration with a hypodermic needle into theperi-incisional tissues.

Formulation a, Dose and Mode of Administration:

For the Formulation A (132 mg/mL, 660 mg bupivacaine as described above)and vehicle placebo treatment groups, 5 mL of each composition was drawnup and administered using a NORM-JECT® 5-mL Luer Lock syringe connectedto a Tunneltip™ irrigation catheter with a Luer Lock fitting. Thesupplied Tunneltip irrigation catheter was flexible, 15 cm long, 2 mm indiameter, with smooth rounded tip and graduated centimeter markings forwound length measurement and control of instillation. To account for thedead space in the catheter, sites were instructed to draw 5.5 mL ofinvestigational product in the syringe with the provided 16 gaugeneedle. Sites were instructed to purge excess air and investigationalproduct from the syringe and catheter once connected to ensureadministration of 5 mL of each composition. The syringes, needles, andcatheters were supplied sterile and individually packaged.

For laparoscopic portals, each composition was administered directlyinto the open port incision through an irrigation catheter and/or by thesyringe tip. The port incision was then closed with a suture afterdosing. For linear incisions, after closure of the peritoneum andsecuring hemostasis in the subcutaneous space, the irrigation catheterwas placed into the wound and the cutaneous layer was closed over thecatheter with subcuticular stitches. The syringe containing eachcomposition was then attached to the catheter and test drug wasgradually injected while slowly withdrawing the catheter. In this way,each composition (e.g., Formulation A or vehicle control) was evenlydistributed along the length of the incision with minimal leakage of thedrug. A final stitch was used to close the space where the catheter waswithdrawn. The volume delivered per centimeter of wound length wascalculated based on incision length measured using the centimetermarking on the irrigation catheter.

In Cohort 1, the entire 5 mL dose of Formulation A was evenlydistributed within the laparotomy incision. In Cohort2, the larger portincisions received a larger volume of Formulation A than did the smallerport incisions. In Cohort 3, there was generally a 5-10 cm linearincision for exteriorizing the colon for resection and anastomosis (thehand port). Approximately 80-90% of Formulation A was instilled into thehand port using the irrigation catheter method. The remaining 10-20% oftest drug was directly instilled into the laparoscopic port incisions.

To avoid seepage of the product from the wound, instillation wasperformed after a tight closure of the skin with subcuticular stitches(no staples) and Steri-Strips. No drains were placed in the area ofinvestigational product placement.

Results

Efficacy

Two co-primary endpoints were chosen to evaluate the efficacy ofFormulation A compared to control: 1) time normalized AUC of painintensity on movement over 0-72 hours and 2) total amount of rescueopioids taken over 0-72 hours expressed as IV morphine equivalents. Theprimary pain endpoint was defined as the time normalized AUC of pain onmovement over 0-72 hours. The AUC was calculated by the trapezoid methodusing both scheduled pain intensity scores on movement (recordedelectronically on a LogPad device) as well as pain scores recorded eachtime rescue opioids were administered for postoperative pain relief.

Table 17.1 summarizes the primary endpoint AUC of 0-72 hours as well asthe secondary endpoint AUC of 0-48 hours. In addition, the AUC by daywas presented to assess the duration of treatment effect.

TABLE 17.1 Pain Intensity on Movement AUCs by Period (Includes both LogPad and Opioid Pain Scores) LS Mean 95% CI LS Mean for the for thep-value Period Treatment N (SE) 95% CI difference difference (ANCOVA)Cohort 1 (Laparotomy) AUC 0-72 hours Formulation A (5 mL) 26 4.9 (0.43)(4.0, 5.7) −0.89 (−2.11, 0.33) 0.1473 Bupivacaine HCl 17 5.8 (0.51)(4.7, 6.8) AUC 0-48 hours Formulation A (5 mL) 26 5.2 (0.42) (4.4, 6.1)−0.77 (−1.96, 0.42) 0.1953 Bupivacaine HCl 17 6.0 (0.49) (5.0, 7.0) AUC0-24 hours Formulation A (5 mL) 26 5.7 (0.42) (4.9, 6.6) −0.54 (−1.71,0.62) 0.3507 Bupivacaine HCl 17 6.3 (0.48) (5.3, 7.2) AUC 24-48 hoursFormulation A (5 mL) 26 4.7 (0.47) (3.8, 5.7) −1.01 (−2.36, 0.33) 0.1332Bupivacaine HCl 17 5.7 (0.56) (4.6, 6.9) AUC 48-72 hours Formulation A(5 mL) 26 4.1 (0.50) (3.1, 5.1) −1.13 (−2.56, 0.30) 0.1168 BupivacaineHCl 17 5.3 (0.60) (4.0, 6.5) Cohort 2 (Laparoscopic Cholecystectomy) AUC0-72 hours Formulation A (5 mL) 30 2.8 (0.38) (2.0, 3.6) −1.06 (−2.16,0.05) 0.0601 Bupivacaine HCl 20 3.9 (0.45) (3.0, 4.8) AUC 0-48 hoursFormulation A (5 mL) 30 3.2 (0.39) (2.5, 4.0) −1.19 (−2.30, −0.07)0.0371 Bupivacaine HCl 20 4.4 (0.45) (3.5, 5.3) AUC 0-24 hoursFormulation A (5 mL) 30 3.7 (0.40) (2.9, 4.5) −1.17 (−2.33, −0.01)0.0488 Bupivacaine HCl 20 4.8 (0.47) (3.9, 5.8) AUC 24-48 hoursFormulation A (5 mL) 30 2.8 (0.16) (2.5, 3.1) −1.20 (−1.84, −0.56)0.0002 Bupivacaine HCl 20 4.0 (0.22) (3.5, 4.4) AUC 48-72 hoursFormulation A (5 mL) 30 2.0 (0.44) (1.1, 2.9) −0.79 (−2.07, 0.48) 0.2158Bupivacaine HCl 20 2.8 (0.52) (1.7, 3.8) Cohort 3 (LaparoscopicallyAssisted Colectomy) AUC 0-72 hours Formulation A (5 mL) 126 4.8 (0.19)(4.4, 5.2) −0.34 (−0.80, 0.12) 0.1483 Vehicle placebo 77 5.1 (0.23)(4.7, 5.6) AUC 0-48 hours Formulation A (5 mL) 126 5.2 (0.19) (4.8, 5.5)−0.30 (−0.74, 0.14) 0.1829 Vehicle placebo 77 5.5 (0.22) (5.0, 5.9) AUC0-24 hours Formulation A (5 mL) 126 5.4 (0.19) (5.0, 5.8) −0.33 (−0.79,0.12) 0.1489 Vehicle placebo 77 5.8 (0.23) (5.3, 6.2) AUC 24-48 hoursFormulation A (5 mL) 126 4.9 (0.22) (4.4, 5.3) −0.31 (−0.83, 0.20)0.2275 Vehicle placebo 77 5.2 (0.25) (4.7, 5.7) AUC 48-72 hoursFormulation A (5 mL) 126 4.0 (0.24) (3.6, 4.5) −0.40 (−0.97, 0.18)0.1784 Vehicle placebo 77 4.4 (0.29) (3.9, 5.0)

FIGS. 24 to 26 present line graphs of the mean pain intensity onmovement±standard error of the mean (SEM) versus the scheduled time ofpain assessment for each cohort. It can be seen from these Figures thatthe initial pain intensity of Cohorts 1 and 3 was similar, as bothcohorts involved colectomy or other major abdominal surgery, and rangedfrom pain scores of 7 to 8, which was considered severe pain. Cohort 2had a lower initial pain score, ranging from 5 to 6, which wasconsidered moderate to severe pain. In all 3 cohorts, the mean painintensity on movement decreased by 2 to 3 units over a 3-daypostoperative period, with Cohorts 1 and 3 reaching moderate pain levelswhereas Cohort 2 declined to mild pain levels. Cohorts 1 and 2 showed anearly separation of the treatment groups that was maintained over theentire 72-hour period. Cohort 3 had little separation of the treatmentgroups, which was consistent with the relatively small therapeuticeffect observed with the primary endpoint.

Pre-Specified Sensitivity Analyses of Pain Intensity on Movement

A pre-specified sensitivity analysis was a repeated measures mixed modeland is summarized in Table 17.2.

TABLE 17.2 Repeated Measures Pain Intensity on Movement 0-72 Hours Basedon LogPad Scores Only (ITT Population) LS Mean 95% CI LS Mean for thefor the p-value Period Treatment N (SE) 95% CI difference difference(ANCOVA) Cohort 1 (Laparotomy) All Timepoints Formulation A (5 mL) 264.9 (0.30) (4.2, 5.5) −1.0 (−1.83, −0.17) 0.0202 0-72 hr Bupivacaine HCl17 5.9 (0.35) (5.1, 6.6) Cohort 2 (Laparoscopic Cholecystectomy) AllTimepoints Formulation A (5 mL) 30 2.7 (0.27) (2.2, 3.2) −0.9 (−1.66,−0.13) 0.0235 0-72 hr Bupivacaine HCl 20 3.6 (0.32) (3.0, 4.2) Cohort 3(Laparoscopically Assisted Colectomy) All Timepoints Formulation A (5mL) 126 4.7 (0.15) (4.4, 5.0) −0.6 (-0.93, −0.21) 0.0020 0-72 hrVehicle-Placebo 77 5.3 (0.18) (4.9, 5.6) ANCOVA = analysis ofcovariance, CI = confidence interval, ITT = intent-to-treat, LS = leastsquares, SE = standard error

Use of Rescue Medication

The second co-primary endpoint was the mean total amount of opioidsadministered over 0-72 hours, expressed as IV morphine equivalents inmilligrams using standard conversion factors to convert differentopioids to morphine equivalents.

Table 17.3 summarizes the results with respect to the second co-primaryendpoint.

TABLE 17.3 Total Morphine-equivalent Opioid Medication Use by Period andCohort (ITT Population) 95% CI for P-value Treatment Median Median the(Wilcoxon Period Group N (Q1, Q3) Difference Difference Rank-Sum) Cohort1 (Laparotomy) MEDD 0-72 hours (mg) Formulation A 26 87.0 (30.0, 157.0)−1.0 (−54.5, 52.0) 0.9901 (5 mL) Bupivacaine 17 63.0 (34.0, 152.0) HClCohort 2 (Laparoscopic Cholecystectomy) MEDD 0-72 hours (mg) FormulationA 30 17.0 (8.0, 26.0) −5.0 (−14.0, 3.4) 0.2010 (5 mL) Bupivacaine 2022.5 (12.5, 34.5) HCl Cohort 3 (Laparoscopically Assisted Colectomy MEDD0-72 hours (mg) Formulation A 126 52.0 (24.0, 86.6) −3.0 (−15.0, 8.0)0.5897 (5 mL) Vehicle- 77 62.0 (24.0, 86.0) Placebo CI = confidenceinterval, MEDD = mean equivalent daily dose of morphine, ITT =intent-to-treat, Q = quartile

Pharmacokinetics

Plasma PR samples were analyzed for determination of total bupivacaineconcentration only and none of the samples were analyzed fordetermination of free drug concentration. Table 17.4 summarizes the PRparameters for all three cohorts. The graphs of plasma bupivacaineconcentration vs. time after treatment are presented in FIGS. 27 to 29.

TABLE 17.4 Plasma Pharmacokinetic Parameters by Cohort-mean [range]Cohort 1 Cohort 2 Cohort 3 Formulation Bupivacaine FormulationBupivacaine Formulation PK A HCl A HCl A Parameter (N = 30) (N = 18) (N= 30) (N = 20) (N = 129) C_(max) 956 251 752 371 850 (ng/mL) [133-1870][19-551] [357-1850] [101-1170] [92-2850] T_(max) (hr) 48 16 24 1 47median [2-73] [1-48] [1-49] [1-24] [1-74] AUC₍₀₋₇₂₎ 40755 8465 294666772 39437 (ng*hr/mL) [5113-79464] [495-26306] [11095-68124][1777-11985] [3613-110222] AUC_((0-last)) 41942 7784 30997 6623 39602(ng*hr/mL) [635-96625] [465-26364] [11100-68108] [1771-11868][1626-136309]

Safety Evaluation

Patient safety was carefully monitored throughout the trial withtraditional assessments of AEs, vital signs, routine laboratory testing,and Holter monitoring (i.e., continuous recording of electrocardiogram)for 3 days after dosing. Special attention was given to cardiovascularand neurological AE, as bupivacane toxic effects are manifest in thosetwo body systems. In addition, special assessments were done to monitorsurgical wound condition and healing over the 30 days of the trial.

Table 17.5 summarizes the overall adverse experience by cohort.

TABLE 17.5 Overall Summary of Treatment-Emergent Adverse Events, SeriousAdverse Events, and Deaths (Safety Population) Cohort 1 Cohort 2 Cohort3 Formulation Bupivacaine Formulation Bupivacaine Formulation Vehicle AHCl A HCl A Placebo (N = 30) (N = 18) (N = 30) (N = 20) (N = 129) (N =78) At Least One TEAE 30 (100%) 17 (94%) 28 (93%) 20 (100%) 126 (98%) 75(96%) At Least One Cardiovascular  4 (13%)  7 (39%)  2 (7%)  2 (10%)  19(15%)  6 (8%) TEAE At Least One Neurological  6 (20%)  4 (22%) 17 (57%)10 (50%)  23 (18%) 29 (37%) TEAE At Least One Wound Infection  4 (13%) 2 (11%)  1 (3%)  1 (5%)  12 (9%)  2 (3%) REAE At Least One Non-Opioid27 (90%) 17 (94%) 27 (90%) 19 (95%) 124 (96%) 74 (95%) TEAE At Least OneSerious TEAE  9 (30%)  4 (22%)  0  1 (5%)  16 (12%)  9 (12%) At LeastOne TEAE Leading  1 (3%)  0  0  1 (5%)  0  0 to Study DiscontinuationMaximum Relationship to Study Drug Related 12 (40%)  4 (22%) 17 (57%) 10(50%)  79 (61%) 47 (60%) Not Related 18 (60%) 13 (72%) 11 (37%) 10 (50%) 47 (36%) 28 (36%) Maximum Severity Mild  5 (17%)  2 (11%)  4 (13%)  2(10%)  54 (42%) 29 (37%) Moderate 16 (53%) 11 (61%) 16 (53%) 13 (65%) 51 (40%) 32 (41%) Severe  9 (30%)  4 (22%)  8 (27%)  5 (25%)  21 (16%)14 (18%) At Least One Severe and  1 (3%)  0  2 (7%)  1 (5%)  0  2 (3%)Related TEAE At Least One Serious and  1 (3%)  0  0  0  0  1 (1%)Related TEAE Deaths  0  0  0  0  1 (<1%)  0

There were no consistent treatment-related effects on vital signs.Changes in serum chemistry and hematological parameters were thoseexpected after major surgery, with few consistent differences betweentreatment groups. Cardiac safety was carefully studied using Holtermonitoring for 72 hours post-dose, starting about one hour beforesurgery. In addition, baseline 24-hour ambulatory Holter monitoring wasdone after the screening visit. Careful analysis of the Holter data andcorrelation of the QTc interval with bupivacaine plasma concentrationdid not reveal any evidence for QTc prolongation by Formulation A. TheHolter recordings were further analyzed for arrhythmias and no instancesof ventricular tachycardia were detected in any of the recordings.

It is concluded that Formulation A was well tolerated when instilledinto a variety of abdominal surgical wounds at a dose of 5 mL (660 mg)and that there was no evidence of systemic bupivacaine toxicity asassessed by AEs, laboratory testing, and intensive Holter monitoring.With the exception of an increased incidence of post-operative bruising,tissue tolerability of Formulation A compares well to bupivacaine HCl.

Example 18

A double-blind, placebo-controlled pharmacodynamic and pharmacokineticdose response study was conducted to Formulation A instilled directlyinto the wound in patients undergoing open inguinal hernia repair. Inthis study, Formulation A was prepared as described above and includes 3components (sucrose acetate isobutyrate 66 wt %, benzyl alcohol 22.0 wt%, and bupivacaine base 12.0 wt %) that are administered together as asterile solution.

Objectives

To examine the dose response efficacy, pharmacokinetics, safety andtolerability of Formulation A instilled into the wound in patientsundergoing open inguinal hernia repair.

Methods

Study Design

This was a Phase II, multicenter, randomized, double-blind,placebo-controlled, parallel-group, dose-finding study.

Participants

Patients were male or female, 18 to 65 years of age, and were planned toundergo elective open unilateral tension-free Lichtenstein-type inguinalhernia repair under general anesthesia. Patients were in good healthprior to study participation, based on a medical history, physicalexamination, 12-lead electrocardiogram (ECG), and laboratory tests. Allpatients had to have a systolic blood pressure (BP) of <160 mmHg and adiastolic BP of <95 mmHg, use a medically acceptable method ofcontraception throughout the study period and for 1 week aftercompletion of the study, refrain from strenuous activities throughoutthe study period and avoid modifications to prescribed exercise levelsthroughout the study period, and read, understand, communicate, andvoluntarily sign the approved informed consent form prior to theperformance of any study specific procedures.

Patients were excluded if they were pregnant or lactating; had previousabdominal surgery with scar tissue that would limit the patients'ability to participate; had clinically significant hepatic,gastrointestinal, renal, hematologic, urologic, neurologic, respiratory,endocrine, or cardiovascular system abnormalities, psychiatricdisorders, or acute infection unrelated to the disease under study; hadconnective tissue disorders (systemic lupus erythematosus, scleroderma,mixed connective tissue disease); or had a known sensitivity tobupivacaine, or benzyl alcohol (BA). Patients with known or suspectedalcohol abuse within the 6 months prior to study enrollment or illicitdrug use, current or regular use of analgesic medication for otherindication(s), current or regular use of triptyline or imipramineantidepressants, or monoamine oxidase inhibitors; or use of anyprescription drugs or over the counter medication that started within 7days before treatment and throughout the study (except for birth controlmedications) that might interfere with the conduct or interpretation ofthe study results were excluded, as were patients who participated inanother clinical study concurrent or within 30 days of enrollment andthose who were unwilling or unable to comply with the study procedures.

Interventions

The inguinal hernia operative procedure was performed according tostandard local practice under general anesthesia. Patients wererandomized to receive 2.5 mL or 5.0 mL of Formulation A (12.0 wt %, 132mg/mL bupivacaine), or 2.5 mL or 5.0 mL of Placebo. All treatments wereadministered during wound closure, and were instilled graduallythroughout the inguinal canal and the abdominal wall layers to cover allraw surfaces of the wound, filling the subaponeurotic and subcutaneousspaces.

Outcome Measures

Pain intensity at rest and on movement was evaluated using a numericalrating scale ([NRS] 0=no pain; 10=worst pain possible) on Day 0 at 1, 2,3, 4, 6, 8, 10, and 12 hours following medication administration, onDays 1 to 4 at 8:00 am, 12:00 μm, 4:00 μm, and 8:00 μm, on Day 5 at 8:00am, and prior to dosing with any rescue medication from Day 0 to 14. Themodified Brief Pain Inventory was completed once daily at 12:00 μm onDays 1 to 5. Postoperative analgesia was prescribed according to asuggested guideline, and rescue medication use, concomitant medications,and adverse events (AEs) were recorded throughout the study. Time fromsurgery to patient mobilization, typical bowel movement pattern, lastbowel movement prior to surgery, and the number of bowel movements aftertreatment were measured. Blood samples were collected forpharmacokinetic analysis for a minimum of 32 patients on Day 0 at −5min, and 1, 2, 3, 4, 8, and 12 hours, and on Days 1 to 4, and 7 atapproximately the same time of day that the treatment was administeredon Day 0. Surgical site healing and local tissue conditions evaluated atfollow up visits on Days 1 to 4, 7, and 14, where appropriate. Specificsafety evaluations performed as part of the modified Brief PainInventory included nausea/vomiting, drowsiness, itching, constipation,dizziness, tinnitus, dysgeusia, and paresthesia. Vital signs wererecorded at screening, on Day 0 prior to and immediately followingtreatment administration, and hourly thereafter up to the 8-hourevaluation time point or discharge (whichever occurred first), as wellas on Days 1 to 3, and 14. Physical examinations and safety laboratoryassays were performed at screening and on Day 14. A 12-lead ECG wasperformed at screening and when clinically indicated to evaluate andrecord all clinically significant abnormalities (e.g., bradycardiaepisodes); 2 study centers performed continuous ECG monitoring for 24hours as soon as practical after the surgical procedure and, ifclinically indicated, a 12-lead ECG was performed. Patients returned toclinic for 3- and 6-month follow-up visits for physical examinations,evaluations of surgical site healing and local tissue conditions, andcollections of adverse event and concomitant medication data.

Sample Size

Approximately 144 patients were randomized to the study in order toyield 120 total evaluable patients (60 patients per cohort with a 3:1randomization in favor of active treatment within each cohort). Arelative treatment effect of 0.67 (between Formulation A 5.0 mL andFormulation A 5.0 mL groups) was detected based on the mean painintensity on movement area under the curve (AUC) over the period of 1 to72 hours with 80% power and a 5% significance level.

Randomization

Prior to surgery, eligible patients were randomly assigned to receiveone of the following 4 treatments: Formulation A 5.0 mL (660 mg ofbupivacaine), Formulation A 2.5 mL (330 mg of bupivacaine), Placebo 5.0mL, or Placebo 2.5 mL. Each randomized patient received a randomizationnumber comprising the cohort membership (Cohort 1 or Cohort 2; 60randomized patients per cohort as defined below) and a treatment group(3:1 randomization in favor of active treatment). Placebo groups (2.5 mLand 5.0 mL) were pooled a priori to potentially increase the statisticalanalysis power.

The 2 cohorts were as follows:

-   -   Cohort 1: Patients were randomized to receive either 2.5 mL of        Formulation A or 2.5 mL of Placebo;    -   Cohort 2: Patients were randomized to receive either 5.0 mL of        Formulation A or 5.0 mL of Placebo.        This randomization scheme resulted in 3 distinct treatment        groups, as follows:    -   Treatment Group 1: Formulation A 2.5 mL (330 mg of bupivacaine);    -   Treatment Group 2: Formulation A 5.0 mL (660 mg of bupivacaine);    -   Treatment Group 3: Placebo 2.5 mL or 5.0 mL, as randomly        assigned.

Number of Patients

Number of Patients Planned

Up to 144 patients were to be enrolled to obtain 120 evaluable patients.

Patients Analyzed

There were 135 patients enrolled and 124 were randomized as follows:Formulation A 2.5 mL, N=45; Formulation A 5.0 mL, N=47; placebo, N=32.Four patients discontinued the study (Formulation A 2.5 mL, N=3;placebo, N=1); thus, 120 patients completed the study and comprised theefficacy evaluable population: Formulation A 2.5 mL, N=42; Formulation A5.0 mL, N=47; placebo, N=31. The safety/per protocol (PP) populationincluded 123 patients (Formulation A 2.5 mL, N=44; Formulation A 5.0 mL,N=47; placebo, N=32), and the intention-to-treat (ITT) populationincluded 122 patients (Formulation A 2.5 mL, N=43; Formulation A 5.0 mL,N=47; placebo, N=32).

Diagnosis and Main Criteria for Inclusion

Male and female patients, in good general health, 18 to 65 years of age,who were planned to undergo elective open unilateral tension-freeLichtenstein-type inguinal hernia repair under general anesthesia.

Duration of Treatment

Treatment was administered at one time on the day of surgery (Day 0).

Criteria for Evaluation

Efficacy

There were 2 coprimary efficacy endpoints: the mean pain intensity onmovement normalized AUC over the time period 1 to 72 hours post-surgery,and the proportion of patients who received opioid rescue medicationduring the study. Primary null hypotheses were no differences betweentreatment groups in terms of mean pain intensity on movement normalizedAUC or opioid rescue medication. Secondary efficacy endpoints includedthe following: mean pain intensity normalized AUC over the time periodof 1 to 48 hours post-surgery, post-surgery time-to-opioid medicationuse, overall treatment satisfaction, mean total opioid dose convertedinto morphine equivalence for analgesia rescue during the study, andmean function activities (Days 1 through 5). Exploratory analysesincluded calculations of normalized mean pain intensity AUCs (onmovement and at rest) for 1 to 24 hours, 1 to 96 hours, and 1 to 120hours (using the last observation carried forward [LOCF] method).

Pharmacokinetics

Plasma samples were collected in a subset of patients at one selectedstudy center for pharmacokinetic assessments.

Safety

Safety outcomes included AEs, surgical site healing and local tissuecondition evaluations, ECGs, laboratory tests, vital signs, and physicalexaminations.

Statistical Methods

Primary Endpoints

The mean pain intensity AUC was compared between treatment groups usingan Analysis of Variance (ANOVA) model that included treatment group andstudy site as factors. A Dunnett test was used to carry out the pairwisecomparison of the placebo group (aggregated) and the two Formulation Adoses. The proportion of patients who received opioid rescue medicationwas analyzed using a Cochran-Mantel-Haenszel (CMH) test.

Secondary Endpoints

Time-to-opioid use was analyzed using a log-rank test. The Coxproportional hazards model was also used to estimate the hazard ratioand its 95% confidence interval (CI).

Dose Response

The quantification of the efficacy dose response was examined by testingthe monotonic relationship between the 3 treatment groups (placebo[aggregated], and Formulation A 2.5 mL and 5.0 mL) as a function of painintensity. A step-down approach was used to address multiplicity ofcomparisons.

Results

Efficacy Results

Efficacy results for the primary pain on movement endpoint aresummarized in Table 18.1. The 5 mL dose of Formulation A was highlysignificant compared to placebo, whereas the 2.5 mL Formulation A didnot reach significance, but pain intensity AUC was lower than placebo. Areduction in mean pain intensity at rest normalized AUC from 1 to 72hours was observed in favor of both active doses of Formulation Aagainst placebo, albeit not statistically significant.

TABLE 18.1 Normalized AUC of Pain Intensity on Movement (1-72 hours),ITT Formulation A Formulation A 2.5 mL 5.0 mL Placebo Mean (SEM) 3.11(0.25) 2.47 (0.19) 3.60 (0.30) p-value vs Placebo 0.157 0.0033

The mean pain intensity on movement normalized AUC from 1 to 48 hourswas improved with Formulation A versus placebo, with a statisticallysignificant difference (p=0.0007) observed between 5.0 mL of FormulationA (mean [SEM], 2.52 [0.19]) and placebo (3.86 [0.31]), and a trendtoward significance with 2.5 mL of Formulation A (3.18 [0.24]) versusplacebo (p=0.0654). In addition, the mean pain intensity at restnormalized AUC from 1 to 48 hours trended toward a significantimprovement with 5.0 mL of Formulation A versus placebo (mean [SEM],1.54 [0.13] vs. 2.18 [0.23]; p=0.0515), but the difference between 2.5mL of Formulation A (2.15 [0.22]) and placebo was not statisticallysignificant.

Opioid rescue analgesia after surgery was used in approximately 53.2% (25/47; 95% CI: 38.1%, 67.9%) of patients in the 5.0 mL Formulation Agroup, 72.1% ( 31/43; 95% CI: 56.3%, 84.7%) of patients in the 2.5 mLFormulation A group, and 71.9% ( 23/32; 95% CI: 53.3%, 86.3%) ofpatients in the placebo group; the difference between 5.0 mL ofFormulation A and placebo approached statistical significance in the ITTpopulation (p=0.0909).

The median time-to-first opioid use was greatest with 5.0 mL ofFormulation A (131.8 hours; 95% CI: 31.9, not defined), followed by 2.5mL of Formulation A (10.8 hours; 95% CI: 1.1, 52.7), and then placebo(2.7 hours; 95% CI: 1.1, 25.3); the difference between 5.0 mL ofFormulation A and placebo was statistically significant (p=0.0174).

The IV morphine equivalent dose of rescue medication taken from 0-72hours after treatment is summarized in Table 18.2. Rescue medication usewas significantly lower for Formulation A 5 mL compared to placebo,whereas the 2.5 mL dose of formulation did not reach statisticalsignificance.

TABLE 18.2 IV Morphine Equivalent Use 0-72 Hours (ITT Population)Formulation A Formulation A 2.5 ml 5 ml Placebo N 43 47 32 Mean (SE)11.2 (2.01) 7.9 (1.60) 23.5 (6.85) Median 5.0 2.5 12.5 Formulation A 5ml vs Placebo  Median difference [1] −7.5  95% CI [1] (0.0. 15.0) P-value [2] 0.0085 Formulation A 2.5 ml vs  Median difference [1] −5.0 95% CI [1] (0.0. 10.0)  P-value [2] 0.1333 [1] Hodges-Lehmann estimatesfor median difference [2] [Wilcoxon rank-sum test

Most patients (>90%) in each treatment group were satisfied or verysatisfied, and mean scores for each function activity improved from Day1 to 5 in all 3 treatment groups.

A statistically significant improvement was observed with 5.0 mL ofFormulation A versus placebo in the mean pain intensity on movementnormalized AUC from 1 hour to last (mean [SEM], 2.27 [0.18] vs. 3.03[0.25], respectively; p=0.0211), but not with Formulation A 2.5 mL (2.96[0.25]) versus placebo. Similarly, normalized mean AUCs of painintensity on movement from 1 to 24, 1 to 96, and 1 to 120 hours waslowest with 5.0 mL of Formulation A (mean [SEM], 2.21 [0.21], 2.37[0.18], and 2.30 [0.18], respectively), followed by 2.5 mL ofFormulation A (2.85 [0.25], 3.04 [0.26], and 2.93 [0.26], respectively),and last placebo (4.05 [0.31], 3.31 [0.29], and 3.03 [0.28],respectively).

Pharmacokinetic Results

Plasma concentrations of bupivacaine increased proportionally with thedose administered and there was no burst of drug delivery observed uponadministration of Formulation A. The observed mean (SEM) pharmacokineticparameters of bupivacaine are listed in Table 18.3

TABLE 18.3 Pharmacokinetic 2.5 mL 5.0 mL Parameters Formulation AFormulation A C_(max) (ng/mL), mean (SEM) 466.79 (60.48) 866.57 (114.02)T_(max) (hr), median (range) 12.0 (2.9-24.10) 23.95 (4.0-24.10)AUC_(last) (ng*hr/mL), mean (SEM) 18327.8 (2597.7) 40822.9 (5428.5)AUC_(inf) (ng*hr/mL), mean (SEM) 18542.8 (2636.6) 41461.4 (5404.3)

Safety Results

Safety results reported here refer to the safety population. The mostcommon AEs (incidence of >10% in at least 1 treatment group) in thesafety population (N=123) included somnolence, constipation, dizziness,pruritus, bradycardia, headache, postprocedural hemorrhage,postoperative wound complication, nausea, and dysgeusia. Adverse eventsfrom the modified Brief Pain Inventory (i.e., nausea/vomiting,drowsiness, itching, constipation, dizziness, ringing ears, metallictaste, and numbness or tingling of the toes or fingers) were reported ineach treatment group. The incidence of all AEs probably or possiblyrelated to treatment was 18.2% ( 8/44) in the 2.5 mL Formulation Agroup, 27.7% ( 13/47) in the 5.0 mL Formulation A group, and 28.1% (9/32) in the placebo group, and all were mild or moderate in severity.

Two safety analyses were performed: the original analysis imputedmissing severity data as mild, and an ad-hoc analysis imputed missingseverity data as severe. In both analyses, most AEs (>95% for originalanalysis, >70% for ad-hoc analysis) were mild or moderate in severity; 2patients in each Formulation A group and no patients in the placebogroup in the original analysis and 21 patients treated with FormulationA and 10 placebo-treated patients in the ad-hoc analysis experienced orhad imputed a severe adverse event. Serious adverse events were reportedin 6.8% ( 3/44), 4.3% ( 2/47), and 3.1% ( 1/32) of Formulation A2.5-mL-, Formulation A 5.0-mL-, and placebo-treated patients,respectively; one event (vasovagal syncope) was considered possiblyrelated to Formulation A treatment. Serious adverse events includedacute coronary syndrome, vasovagal syncope, syncope, and postoperativewound complication. There were no deaths or other significant adverseevents.

Nervous system adverse events were reported in 29 (66%), 25 (53%), and23 (72%) Formulation A 2.5-mL-, Formulation A 5.0-mL-, andplacebo-treated patients, respectively. Cardiac adverse events wereexperienced by 10 (23%), 15 (32%), and 7 (22%) patients treated with 2.5mL of Formulation A, 5.0 mL of Formulation A, and placebo, respectively.There were 5 vasovagal syncopal episodes during recovery from generalanesthesia among patients from all dose groups, including placebo.Cardiovascular causes of syncopes were ruled out.

Clinically significant laboratory abnormalities were infrequent andconsisted of 1 positive glucose urine test at screening in the 2.5 mLFormulation A group and 1 high creatine kinase blood level at Day 14 inthe placebo group. Heart rate (HR), BP, respiratory rate, temperature,and physical examination (except gastrointestinal hernia for repair)findings were similar from screening to Day 14 in all treatment groups.The surgical site healed as expected and local tissue conditions were asexpected/normal in 95% of patients in each treatment group at all timepoints evaluated.

On ECG, Formulation A did not result in any clinically relevant changesin HR, PR, QRS, and QT interval corrected for HR durations. The QTcFresult in the regular set of 12-lead ECGs showed a mean change frombaseline placebo corrected +2 ms in the 2.5 mL Formulation A dose groupand −8 ms in the 5.0 mL Formulation A dose group; changes which wouldnot indicate any signal that Formulation A affected cardiacdepolarization or repolarization. However, in the telemetry set of ECGs,the mean change in QTcF duration for 2.5 mL and 5.0 mL of Formulation Afrom baseline to 12 hours was +15 and +9 ms, respectively, and frombaseline to 24 hours was +8 and −11 ms, respectively. These data showeda non-dose related increase in QTcF duration, likely due to lack ofpower, concomitant general anesthesia, and large spontaneous variabilityin QTc durations rather than a direct effect of Formulation A.

During the 6-month follow-up period, there were fewer AEs in the 5.0-mLFormulation A group (35.7%) compared with the placebo group (42.3%) orthe 2.5-mL Formulation A group (58.3%). Most AEs were mild or moderatein severity. Serious AEs were reported at a rate of 11.1% in the 2.5-mLFormulation A group and 7.7% in the placebo group; no serious AEs werereported in the 5.0-mL Formulation A group. Postoperative woundcomplication was the only AE reported in >10% of patients, occurring in7 (19.4%) of patients in the 2.5 mL Formulation A group and 3 (11.5%) ofpatients in the placebo group. Surgical site healing and local tissueconditions were as expected/normal in all patients at 6 months.

Conclusions

5.0 mL of Formulation A (660 mg bupivacaine) instilled directly into thewound was safe and effective in the management of pain in patients whounderwent elective, open, unilateral, tension-free, inguinal herniarepair. 2.5 mL of Formulation A (330 mg bupivacaine) was notdemonstrated to be sufficiently efficacious for pain management ininguinal hernia repair. 5.0 mL of Formulation A (660 mg) significantlyimproved mean pain intensity on movement normalized AUC compared withPlacebo post-surgery for 48 and 72 hours. Patients treated with 5.0 mLof Formulation A (660 mg) required significantly less opioid rescuemedication post-surgery compared with Placebo for 48 and 72 hours. Overthe study period, 5.0 mL of Formulation A (660 mg) significantlyprolonged the time to first opioid use compared with Placebo.

Efficacy endpoints in the 2.5 mL Formulation A (330 mg) group were notstatistically significantly different from Placebo. However, a trendtoward a significant difference versus Placebo was observed with meanpain intensity on movement normalized AUC from 1 to 48 hours and MEDDtaken on Day 2. Patient satisfaction with overall pain treatment wasobserved in each treatment group and persisted throughout the durationof the study. Functional activity improved over time in all treatmentgroups. Pharmacokinetics of bupivacaine is observed to be doseproportional, with no drug release burst observed after administrationof Formulation A.

Most AEs were mild or moderate in severity, and no deaths or othersignificant AEs occurred. During the 6-month follow-up period, seriousAEs were reported at a similar incidence in patients treated with 2.5 mLof Formulation A (330 mg) and placebo, while none were reported inpatients treated with 5.0 mL of Formulation A (660 mg). The activemonitoring of cardiovascular toxicities suggests that no causalassociation was present between the single episodic exposure toFormulation A and cardiac events. Constipation, nausea, pruritus,tinnitus, somnolence, dizziness, headache, dysgeusia, and paresthesiawere reported less frequently with 5.0 mL of Formulation A (660 mg)compared with placebo; however, postprocedural hemorrhage, postoperativewound complication, and bradycardia were reported more frequently with5.0 mL of Formulation A (660 mg) compared with placebo.

The reduction in opioid rescue dose associated with 5.0 mL ofFormulation A (660 mg) reduced the incidence of opioid-related AEs,including dizziness, nausea, and vomiting, and significantly reduced theincidence of constipation compared with placebo. Vital sign or physicalexamination changes over time were minimal. Abnormal or unexpectedsurgical site healing or tissue evaluation, or clinically significantlaboratory abnormalities was observed infrequently and incidences weresimilar between treatment groups. On ECG, Formulation A did notdemonstrate any clinically relevant changes in HR, PR, QRS, or QTcdurations. However, QTcF prolongation was observed, which was notdose-related and was likely due to a small sample size, concomitantgeneral anesthesia, and large spontaneous variability in QTc durations.This study did not demonstrate clear and consistent ECG effects foreither the lower (2.5 mL [330 mg]) or higher (5.0 mL [660 mg]) dose ofFormulation A, suggesting that the higher dose does not expose patientsto a greater risk of untoward cardiovascular effects.

Example 19

A patient-blinded, Phase II study was conducted to examine thepharmacokinetics (PK), safety, tolerability and efficacy of FormulationA instilled directly into the wound in patients undergoing elective openinguinal hernia repair. Operative procedures were performed undergeneral anesthesia. In this study, Formulation A was prepared asdescribed above and includes 3 components (sucrose acetate isobutyrate66 wt %, benzyl alcohol 22.0 wt %, and bupivacaine base 12.0 wt %) thatare administered together as a sterile solution. The aim of using theformulation is to provide prolonged local analgesia by slowly releasingbupivacaine over a period of several days.

Objectives

Primary objective—To examine the pharmacokinetics of a sustained releasebupivacaine composition (i.e., Formulation A containing bupivacaine,benzyl alcohol, sucrose acetate isobutyrate as described above)instilled directly into the wound in patients undergoing elective openinguinal hernia repair.

Secondary objective—To examine the safety, efficacy and tolerability ofFormulation A instilled directly into the wound in patients undergoingelective open inguinal hernia repair.

Methods

The studies was a pilot, patient-blinded, Phase II study to assess thepharmacokinetics, safety, tolerability and efficacy of Formulation A asa delivery system in open inguinal hernia repair patients. The studyinvestigated instillation of Formulation A directly into the wound, withpatients being enrolled into two treatment groups:

Treatment Group 1—During wound closure 2.5 mL of Formulation A wasplaced topically, in approximately equal volumes, into the superior,medial and inferior subaponeurotic spaces. After closure of the externaloblique aponeurosis (and prior to skin closure) a further 2.5 mL ofFormulation A was placed topically along the length of the suturedexternal oblique aponeurosis. The total delivered volume of FormulationA instilled into the wound was 5.0 mL.

Treatment Group 2—After closure of the external oblique aponeurosis (andprior to skin closure) 5.0 mL of Formulation A was placed topicallyalong the length of the sutured external oblique aponeurosis. The totaldelivered volume of Formulation A instilled into the wound was 5.0 mL.

Number of patients: Patients planned—Up to 12 patients, with six pertreatment group to achieve five evaluable patients per group; PatientsEntered—12 patients, with six per treatment group; Patients Completed—12patients, with six per treatment group.

Diagnosis and main criteria for inclusion of patient into study: Thestudy population included male and female patients undergoing openrepair of inguinal hernia under general anaesthesia.

Duration of TREATMENT

The study period lasted up to 21 days.

Criteria for Evaluation:

Efficacy: Daily pain intensity (numerical rating scale), daily opioidrescue analgesia and total daily analgesia. A modified brief paininventory was used to assess daily pain control, worst pain, least pain,analysis of function, treatment satisfaction and individual painintensity over time.

Safety: Adverse effects (AEs), wound healing and local tissueconditions, laboratory tests, physical examination and vital signs. Themodified brief pain inventory also recorded certain safety evaluationsincluding: nausea, vomiting, drowsiness, itching, constipation,dizziness, tinnitus, dysgeusia, parasthesia and the number of bowelmovements following injection of study drug.

Pharmacokinetic: Non-compartmental PK analysis was performed on allpatient data from whom PK blood samples were collected.

Statistical Methods:

The aim was for five evaluable patients to complete treatment in eachgroup was used as the sample size calculation for this study.

Plasma bupivacaine concentration was summarized at each timepoint andWinNonLin was used to assess the data. The parameters of maximum plasmaconcentration (Cmax), time taken to reach Cmax (Tmax) and area under thecurve (AUC), using the linear trapezoid rule, were summarized bytreatment group and compared using a linear general method.

A plot of mean pain intensity score at pre-determined time points wasused to assess both treatment groups simultaneously. Modified brief paininventory data were summarized by treatment group, with pain control,worst pain and least pain summarized using an AUC. All pain assessmentdata were summarized by treatment group.

All opioid containing drugs were coded into morphine equivalents and thetotal morphine equivalent daily dose was calculated for each day. Theaverage number of rescue analgesic tablets taken per day for Days 0-5,6-14 and overall (Days 0-14) were calculated and summarized by treatmentgroup. The proportion of patients who required no rescue analgesiaduring Days 0-5 was summarized by treatment group.

The overall incidence (number and percentage) of treatment emergent AEsand serious adverse events (SAEs) were summarized by treatment group.The incidence of AEs was also assessed in terms of maximum severity andrelationship to study medication, for each MedDRA system organ class andpreferred term. The proportion of patients reporting each common safetyevent recorded by the modified brief pain inventory was summarized bytreatment group. Surgical site healing and local tissue condition datawere listed and summarized by treatment group.

Vital signs data, changes from baseline and the number and proportion ofpatients with abnormal findings in each body system were summarized bytreatment group at each visit. Data on typical bowel function weresummarized and the number of bowel functions in each 24-hour period wassummarized by treatment group. Concomitant medications taken weresummarized by treatment group using ATC and WHO drug codes.

Laboratory data were listed, compared with sex-specific normal rangesand any changes from screening to the end of the study were calculated.The observed data and changes from screening were summarized bytreatment group. Shift tables of hematology and biochemistry parametersbetween abnormally low/normal/abnormally high values from baseline tothe end of treatment were produced by treatment group. The proportion ofpatients with abnormal values considered clinically significant wascompared between treatment groups.

Results

Efficacy Results

In Treatment Group 1 where Formulation A was instilled into thesubaponeurotic space and along the external oblique aponeurosis, themean pain intensity scores at rest remained at a similar level over Days0-1 and began to fall on Day 2. In Treatment Group 2 where Formulation Awas instilled along the external oblique aponeurosis alone there was aslight increase in mean pain intensity scores from Day 0 to Day 1, witha subsequent reduction in pain levels on Days 2-3. Overall the mean painintensity scores for Days 2-5 were consistently higher in TreatmentGroup 2 patients than in Treatment Group 1 patients and the painintensity AUCs were also higher for patients in Treatment Group 2.(Table 19.1)

TABLE 19.1 Pain Intensity Scores at Rest (ITT Population) SubaponeuroticSpaces + Oblique Aponeurosis Oblique Aponeurosis Alone (Group 1) (N = 6)(Group 2) (N = 6) Time Mean ± SEM Median (95% CI) Mean ± SEM Median (95%CI) Day 0 4 hours 1.2 ± 0.65 0.5 (0.0, 4.0) 0.8 ± 0.40 0.5 (0.0, 2.0) 6hours 0.8 ± 0.65 0.0 (0.0, 4.0) 0.5 ± 0.22 0.5 (0.0, 1.0) 8 hours 0.8 ±0.65 0.0 (0.0, 4.0) 0.7 ± 0.33 0.5 (0.0, 2.0) 10 hours 0.8 ± 0.65 0.0(0.0, 4.0) 1.5 ± 0.22 1.5 (1.0, 2.0) 12 hours 0.7 ± 0.49 0.0 (0.0, 3.0)1.5 ± 0.22 1.5 (1.0, 2.0) Day 1 08:00 hours 0.5 ± 0.34 0.0 (0.0, 2.0)2.3 ± 0.61 2.0 (1.0, 4.0) 12:00 hours 0.8 ± 0.40 0.5 (0.0, 2.0) 1.2 ±0.48 1.0 (0.0, 3.0) 16:00 hours 1.3 ± 0.49 1.5 (0.0, 3.0) 1.5 ± 0.67 1.0(0.0, 4.0) 20:00 hours 1.3 ± 0.49 1.5 (0.0, 3.0) 1.3 ± 0.76 1.0 (0.0,5.0) Day 2 08:00 hours 0.8 ± 0.40 0.5 (0.0, 2.0) 1.2 ± 0.60 1.0 (0.0,4.0) 12:00 hours 0.8 ± 0.31 1.0 (0.0, 2.0) 1.3 ± 0.61 1.0 (0.0, 4.0)16:00 hours 0.2 ± 0.17 0.0 (0.0, 1.0) 1.2 ± 0.60 1.0 (0.0, 4.0) 20:00hours 0.5 ± 0.34 0.0 (0.0, 2.0) 1.0 ± 0.60 0.5 (0.0, 4.0) Day 3 08:00hours 0.2 ± 0.17 0.0 (0.0, 1.0) 0.8 ± 0.65 0.0 (0.0, 4.0) 12:00 hours0.2 ± 0.17 0.0 (0.0, 1.0) 1.0 ± 0.63 0.5 (0.0, 4.0) 16:00 hours 0.3 ±0.21 0.0 (0.0, 1.0) 0.8 ± 0.65 0.0 (0.0, 4.0) 20:00 hours 0.2 ± 0.17 0.0(0.0, 1.0) 0.8 ± 0.65 0.0 (0.0, 4.0) Day 4 08:00 hours 0.2 ± 0.17 0.0(0.0, 1.0) 1.0 ± 0.82 0.0 (0.0, 5.0) 12:00 hours 0.3 ± 0.33 0.0 (0.0,2.0) 1.2 ± 0.79 0.5 (0.0, 5.0) 16:00 hours 0.2 ± 0.17 0.0 (0.0, 1.0) 1.0± 0.82 0.0 (0.0, 5.0) 20:00 hours 0.3 ± 0.21 0.0 (0.0, 1.0) 1.0 ± 0.820.0 (0.0, 5.0) Day 5 08:00 hours 0.2 ± 0.17 0.0 (0.0, 1.0) 0.8 ± 0.650.0 (0.0, 4.0) 12:00 hours 0.3 ± 0.21 0.0 (0.0, 1.0) 0.8 ± 0.65 0.0(0.0, 4.0) AUC 0-120 hours 68.4 ± 36.86 31.0 (3.0, 240.2) 140.3 ± 67.88 61.4 (29.3, 462.8) SEM = standard error of mean; CI = confidenceinterval

A similar pattern was seen for pain intensity scores on movement. Mostpatients experienced good, very good or excellent pain control fromFormulation A instillation into the wound, with only two patients inTreatment Group 2 experiencing fair pain control. No notable differencesbetween treatment groups were seen when comparing pain control AUCvalues. The worst pain scores were higher on Day 1 in Treatment Group 2but by Day 2 there were no notable differences between the treatmentgroups. The impact of post-surgical pain on ability to walk, socialinteractions, stay asleep and to cough was higher in Treatment Group 2on Day 1, but by Day 2 was comparable between the two groups for mostparameters. Most patients were satisfied or very satisfied withFormulation A treatment, with only two patients in Treatment Group 2(i.e., where Formulation A was instilled along the external obliqueaponeurosis alone) being fairly dissatisfied or only fairly satisfiedwith treatment. No differences between the two groups were seen for theother efficacy parameters evaluated.

More patients in Treatment Group 2 where Formulation A was instilledalong the external oblique aponeurosis alone required rescue analgesiabetween Days 0-5 compared to patients in Treatment Group 1 whereFormulation A was instilled into the subaponeurotic space as well asalong the external oblique aponeurosis. However, patients in TreatmentGroup 2 only required rescue analgesia over Days 0-5, whereas onepatient in Treatment Group 1 required rescue analgesia during Days 6-14.

TABLE 19.2 Total Daily Dose of Rescue Analgesia (tablets, ITTPopulation) Subaponeurotic Spaces + Oblique Oblique Aponeurosis AloneAponeurosis (Group 1) (N = 6) (Group 2) (N = 6) Time Mean ± SEM Median(95% CI) Mean ± SEM Median (95% CI) Days 0-5 2.0 ± 1.63 0.0 (0.00,10.00) 3.0 ± 1.24 3.0 (0.00, 8.00) Days 6-14 0.3 ± 0.33 0.0 (0.00, 2.00)0.0 ± 0.00 0.0 (0.00, 0.00) Overall 2.3 ± 1.96 0.0 (0.00, 12.00) 3.0 ±1.24 3.0 (0.00, 8.00)

Opioid analgesia used during the study was converted into intravenousmorphine equivalent daily doses (MEDD) unit and the resultingsupplemental opioid analgesia usage is summarized the table below.During the first 24 hours post-surgery, patients in Treatment Group 2required more opioid therapy than patients in Treatment Group 1.However, after this 24-hour period, none of the patients in TreatmentGroup 2 required additional opioid analgesia, whereas some patients inTreatment Group 1 required opioid analgesia throughout Days 1-5.

TABLE 19.3 Summary of Opioid Analgesia Usage (MEDD, ITT Population)Subaponeurotic Spaces + Oblique Oblique Aponeurosis Alone Aponeurosis(Group 1) (N = 6) (Group 2) (N = 6) Time Mean ± SEM Median Range Mean ±SEM Median Range  1-24 hours 0.83 ± 0.833 0.00 0.0-5.0 2.50 ± 5.500 0.00 0.0-15.0 24-48 hours 1.67 ± 1.667 0.00  0.0-10.0 0.00 ± 0.000 0.000.0-0.0 48-72 hours 1.67 ± 1.054 0.00 0.0-5.0 0.00 ± 0.000 0.00 0.0-0.072-96 hours 0.00 ± 0.000 0.00 0.0-0.0 0.00 ± 0.000 0.00 0.0-0.0 96-120hours 0.83 ± 0.833 0.00 0.0-5.0 0.00 ± 0.000 0.00 0.0-0.0 Days 1-5 1.00± 0.816 0.00 0.0-5.0 0.50 ± 0.500 0.00 0.0-3.0

Safety Results

The incidence of AEs was comparable between treatment groups. The onlyAEs reported in more than one patient per treatment group werepost-procedural hemorrhage (three of six patients) and nausea (two ofsix patients). Nausea was experienced across both treatment groups onthe day following surgery, whereas post-procedural hemorrhage was onlyexperienced by patients in Treatment Group 1. Drowsiness andconstipation were reported by individual patients within the first twodays of the study. All AEs were mild (three of six patients in TreatmentGroup 2) or moderate (four of six patients in Treatment Group 1) inseverity and none were considered related to the study treatment.

There were no deaths or withdrawals during the study. Only one patientexperienced a severe adverse effect (SAE), comprising recurrence ofinguinal hernia in a patient in Treatment Group 1. The SAE was notconsidered related to the study treatment and resolved over the courseof the study.

The administration of Formulation A directly into the wound at a dose of5.0 mL did not raise safety concerns over clinical laboratory, vitalsigns or physical examination parameters. In addition, the use ofFormulation A did not appear to compromise wound healing, thoughabnormal local tissue conditions were recorded for three of the 12patients. Administration of Formulation A to the subaponeurotic spaceand along the external oblique aponeurosis appeared to be associatedwith a slightly faster return to normal bowel function.

Pharmacokinetic Results

Quantifiable plasma bupivacaine concentrations were observed within 1-4hours of Formulation A administration, which increased gradually tomaximum concentrations around 12-24 hours in both the treatment groups.Sustained levels (between 100-400 ng/mL) were generally maintained for aperiod of 48-72 hours and then the concentrations started to decline inmono-exponential order.

In this study, the two treatment groups were different with respect tothe method of drug administration, but the total volume of drugadministered was 5.0 mL for both the groups. Overall pharmacokineticparameters of bupivacaine between the two groups were similar, withsomewhat higher variability in Group 2 (entire amount as woundinfiltrate).

After correcting for the actual dose administered and normalizing to 1mL dose, the plasma bupivacaine concentration seemed almostsuperimposable.

Conclusions

The pharmacokinetics of bupivacaine were similar between the two groupsevaluated in this study. This study showed that Formulation A, instilledinto either the subaponeurotic space and along the external obliqueaponeurosis (Treatment Group 1) or instilled along the external obliqueaponeurosis alone (Treatment Group 2), at a dose of 5.0 mL was welltolerated and not result in any clinically significant AEs. Instillationof Formulation A into the subaponeurotic space and along the externaloblique aponeurosis (Treatment Group 1) showed better efficacy,particularly on Day 1, in terms of pain intensity scores, as well as theamount of time pain interfered with the ability to walk, socialinteractions, ability to stay awake and to cough. The patient'sassessment of their overall pain control and satisfaction with treatmentwas higher when Formulation A was instilled into the subaponeuroticspace and along the external oblique aponeurosis (Treatment Group 1)compared to along the external oblique aponeurosis alone (TreatmentGroup 2). Instillation of Formulation A into the subaponeurotic spaceand along the external oblique aponeurosis (Treatment Group 1) wasassociated with a reduced requirement for supplemental rescue and opioidanalgesia in the first few days post-surgery.

Example 20

A randomized, double-blind, placebo-controlled study was conducted toexamine the efficacy, tolerability and safety of Formulation Aadministered subcutaneously or into the subaponeurotic space in subjectsundergoing elective open inguinal hernia repair. In this study,Formulation A and placebo was prepared as described above and issummarized below:

Composition: Formulation A-Sustained Release Bupivacaine CompositionActive ingredient: Bupivacaine base Inactive ingredients: Sucroseacetate isobutyrate, benzyl alcohol Strength: 132 mg/mL, 660 mgbupivacaine

Composition Placebo Active ingredient: Not applicable Inactiveingredients: Sucrose acetate isobytyrate, benzyl alcohol

Objectives

Primary objective—The primary objective was to determine the efficacy ofFormulation A administered subcutaneously or into the subaponeuroticspace in subjects undergoing elective open inguinal hernia repair.

Secondary objective—The secondary objectives were to determine thesafety and tolerability of Formulation A administered subcutaneously orinto the subaponeurotic space in subjects undergoing elective openinguinal hernia repair.

Since the mode of administration was different between Cohort 1 andCohort 2, the study objectives were defined specifically for eachcohort.

Methods

This was a randomized, double-blind, placebo-controlled, Phase 2 studyto examine the efficacy of Formulation A instilled throughout thesubaponeurotic and subcutaneous spaces, administered by injection intothe subaponeurotic space, or administered subcutaneously in subjectsundergoing elective open inguinal hernia repair and to assess the safetyand tolerability of Formulation A as a delivery system.

The study was conducted in 2 separate and sequential cohorts (Cohort 1and Cohort 2, summarized below). Approximately equal numbers of subjectswere to be enrolled, in sequence, to each cohort. The study duration wasup to 21 days that included screening, admission to clinic and surgery(Day 0), postoperative evaluations, discharge from clinic, and follow-upthrough Day 14.

The subjects were evaluated on Days 1, 2, 4, and 5 by telephone andreturned to the clinic on Days 3 and 14 (follow-up). Subjects recordedpain intensity (PI), concomitant medications, adverse events (AEs), andrescue analgesia on diary cards from Days 0 through 5. Subjects alsorecorded AEs and concomitant medications through Day 14.

Cohort 1

Immediately prior to surgery, the first 45 subjects were randomlyassigned in a 1:1:1 ratio to receive 1 of the following treatments:

Treatment Group 1: Prior to wound closure, 5.0 mL of Placebo wasinjected into the superior, medial, and inferior subaponeurotic spaces.After wound closure, Formulation A was administered as 2 trailingsubcutaneous injections along each side of the incision line (suggestedincision total length to be 4 to 6 cm). The total delivered volume ofFormulation A was 5.0 mL.

Treatment Group 2: Prior to wound closure, 5.0 mL of Formulation A (12.0wt %, 132 mg/mL bupivacaine was injected into the superior, medial, andinferior subaponeurotic spaces. After wound closure, Placebo wasadministered as 2 trailing subcutaneous injections along each side ofthe incision line (suggested incision total length to be 4 to 6 cm). Thetotal delivered volume of Placebo was 5.0 mL.

Treatment Group 3: Prior to wound closure, 5.0 mL of Placebo wasinjected into the superior, medial, and inferior subaponeurotic spaces.After wound closure, Placebo was administered as 2 trailing subcutaneousinjections along each side of the incision line (suggested incisiontotal length to be 4 to 6 cm). The total subcutaneously delivered volumeof Placebo was 5.0 mL. The total delivered volume of Placebo was 10.0mL.

Cohort 2

Immediately prior to surgery, the second group of 45 subjects wasrandomly assigned in a 1:1 enrollment ratio to receive 1 of thefollowing treatments:

Treatment Group 4: During the wound closure, 5.0 mL of Placebo wasinstilled gradually throughout the inguinal canal and the abdominal walllayers to cover all raw surfaces of the wound, filling up subaponeuroticand subcutaneous spaces.

Treatment Group 5: During the wound closure, 5.0 mL of Formulation A wasinstilled gradually throughout the inguinal canal and the abdominal walllayers to cover all raw surfaces of the wound, filling up subaponeuroticand subcutaneous spaces (7.5 mL specified for Cohort 2a comprisingTreatment 5a).

Number of Subjects: The planned enrollment was 90 subjects in order toensure 72 evaluable subjects who planned to undergo ambulatory openrepair of inguinal hernia. The 90 subjects were to be divided evenlyinto 45 subjects in each cohort.

The final goal was for at least 72 evaluable subjects to complete thestudy (36 subjects in each cohort, 12 subjects in each treatment groupof Cohort 1 and 18 in each treatment group of Cohort 2).

A total of 45 subjects were enrolled in Cohort 1; 13 to Treatment 1, 18to Treatment 2, and 14 to Treatment 3. All 45 subjects completedCohort 1. A total of 44 subjects were enrolled in Cohort 2; 21 toTreatment 4, 1 to Treatment 5a, and 22 to Treatment 5. Forty-onesubjects completed Cohort 2; 1 subject in Treatment 4 and 2 subjects inTreatment 5 were lost to follow-up.

Diagnosis and main criteria for inclusion of patient into study: Thestudy population included male and female subjects who were planning toundergo ambulatory open repair of inguinal hernia requiring an incisionof 4 to 6 cm in length, were in good health, and were above 18 years ofage.

Test Product, Dose and Mode of Administration

Cohort 1

Treatment 1: 10.0-mL vials of Formulation A (12.0 wt %) were used tofill 5.0-mL syringes for a 5.0-mL subcutaneous injection.

Treatment 2: 10.0-mL vials of Formulation A (12.0 wt %) were used tofill 5.0-mL syringes for injection of 5.0 mL into the superior, medial,and inferior subaponeurotic spaces.

Cohort 2

Treatment 5a: 10.0-mL vials of Formulation A (12.0 wt %) were used tofill 10.0-mL syringes to instill 7.5 mL into subaponeurotic andsubcutaneous spaces.

Treatment 5: 10.0-mL vials of Formulation A (12.0 wt %) were used tofill 10.0-mL syringes to instill 5.0 mL into subaponeurotic andsubcutaneous spaces.

Reference Therapy, Dose and Mode of Administration

Cohort 1

Treatment 1: 10.0-mL vials of Placebo were used to draw 5.0-mL syringesfor injection of 5.0 mL into the superior, medial, and inferiorsubaponeurotic spaces.

Treatment 2: 10.0-mL vials of Placebo were used to draw 5.0-mL syringesfor a 5.0-mL subcutaneous injection.

Treatment 3: 10.0-mL vials of Placebo were used to draw 5.0-mL syringesfor a 5.0-mL subcutaneous injection and an injection of 5.0 mL into thesuperior, medial, and inferior subaponeurotic spaces.

Cohort 2

Treatment 4: 10.0-mL vials of Placebo (12.0 wt %) were used to draw10.0-mL syringes to instill 5.0 mL into subaponeurotic and subcutaneousspaces.

Duration of Treatment

Subjects received a single dose of Formulation A. The study duration wasup to 21 days comprising screening, admission to clinic and surgery (Day0), postoperative evaluations, discharge from clinic, and follow-upthrough Day 14.

Criteria for Evaluation:

Efficacy: Efficacy was assessed using the subjects' self-evaluation ofPI and pain management collected on subject diaries (Days 0 to 5), theModified Brief Pain Inventory (Days 1 to 5), and the subjects' use ofconcomitant rescue analgesic medication (Days 0 to 14). The primaryefficacy endpoints were PI and pain control. The secondary efficacyendpoints were worst and least pain scores, rescue analgesia usage,function, overall treatment satisfaction, and individual PI scores overtime.

Safety: Safety evaluations included AEs; assessments of laboratory testssuch as chemistry, hematology, and urinalysis; a serum pregnancy test(if applicable); periodic monitoring of vital signs; 12 leadelectrocardiogram (ECG); concomitant medications; and physicalexaminations. Evaluations also included surgical site healing and localtissue conditions.

Statistical Methods:

Tables and listings were produced using SAS version 8.2. All efficacyand safety data collected on the case report form (CRF) were presentedin listings ordered by treatment group, site, subject number, date, andtime. Data summaries by treatment group were presented. For continuousvariables, data were summarized with the number of subjects (n), mean,standard deviation (SD), median, minimum, and maximum by treatmentgroup. For categorical variables, data were tabulated with number andproportion of subjects for each category by treatment group.

Statistical tests were performed using 2-sided tests at the 5%significance level. Because of the exploratory nature of this Phase 2study, no multiplicity adjustment was made for any of the analyses.

The comparison of primary interest was between Treatment 5 and PooledPlacebo. The significance of comparisons between Formulation A,Treatment 2 and Treatment 1 and Pooled Placebo were also reported.

The incidence (number and percentage) of treatment-emergent AEs wasreported for each treatment group by Medical Dictionary for RegulatoryActivities (MedDRA) Version 8.0 system organ class and preferred term. Aseparate overall incidence summary was presented for AEs with onset onDay 0.

Specific safety evaluations of the Modified Brief Pain Inventory weretabulated by study day and treatment. Incidence across all study dayswas also summarized by treatment.

Surgical site healing and local tissue condition evaluation wassummarized and tabulated by subject incidence (n and percent) for eachtreatment group over time.

All laboratory test results were listed by subject, laboratory panel andparameter, and collection time.

Abnormal or change from screening physical examination results werepresented in a listing.

Vital signs were listed descriptively for each treatment group at eachcollection time point. Changes from baseline (predose) vital signs weresummarized for each treatment and scheduled interval. Repeat readingswere not used in these summaries.

Screening and unscheduled ECGs were presented in a listing.

Results

Efficacy Results:

The results of the per-protocol (PP) population analysis showed that,for the primary endpoint of PI during movement, the Formulation Atreatment groups were not significantly better than the pooled Placebogroup. Treatments 1 (5.0 mL Formulation A, subcutaneous) and 2 (5.0 mLFormulation A, subaponeurotic) were numerically better than placebo, butthese differences did not reach statistical significance. For theprimary endpoint of PI at rest, similar results were observed. The onlystatistically significant difference represented a higher PI value inTreatment 5 (5.0 mL Formulation A) compared to Pooled Placebo (P=0.014).In the analysis of secondary endpoints, the time to first rescueanalgesia was significantly longer for Treatment 2 (5.0 mL FormulationA, subaponeurotic) than for Pooled Placebo (P=0.009).

A post hoc analysis of PI over time was conducted for the 2 cohortsseparately. In Cohort 1, pain assessments were not significantlydifferent between the 3 treatment groups. The Formulation Asubaponeurotic and subcutaneous treatment groups required less opioiduse during the evaluation period compared to placebo. In Cohort 2, notrend in reduction of overall cumulative opioid rescue medication use inthe Formulation A treatment groups versus placebo was observed.

Safety Results:

The overall frequency of adverse effects (AEs) was similar betweentreatment groups. The most commonly reported treatment-emergent AEs werenausea (46 events total; 6 in Treatment 1, 10 in Treatment 2, 12 inTreatment 5, 1 in Treatment 5a, and 17 in Pooled Placebo), dizziness (42events total; 4 in Treatment 1, 5 in Treatment 2, 13 in Treatment 5, 0in Treatment 5a, and 20 in Pooled Placebo), constipation (40 eventstotal; 5 in Treatment 1, 7 in Treatment 2, 15 in Treatment 5, 0 inTreatment 5a, and 13 in Pooled Placebo), and somnolence (38 eventstotal; 4 in Treatment 1, 2 in Treatment 2, 13 in Treatment 5, 1 inTreatment 5a, and 18 in Pooled Placebo). The majority oftreatment-emergent AEs were of mild or moderate severity. There were nodeaths or discontinuations due to AEs. Three severe adverse effects(SAEs) occurred (syncope vasovagal, orthostatic hypotension, andoliguria); all of these events were moderate in intensity and none wereconsidered related to study drug by the investigator.

An analysis of specific safety evaluations of interest did not indicateany opioid-related safety issues. Nausea, somnolence, dizziness, andconstipation were reported by approximately 50% of subjects in alltreatment groups. Vomiting, tinnitus, pruritus, dysgeusia, andparesthesia also occurred with high frequency. There were severaldifferences in the frequency of occurrence of these events between theFormulation A and Pooled Placebo treatment groups: vomiting occurred in7 subjects ( 7/40, 17.5%) in the Formulation A treatment group comparedto 3 subjects ( 3/35, 8.6%) in the placebo group; dysgeusia occurred in3 subjects ( 3/40, 7.5%) in the Formulation A treatment group comparedto 6 subjects ( 6/35, 17.1%) in the placebo group; and paresthesiaoccurred in 4 subjects ( 4/40, 10.0%) in the Formulation A treatmentgroup compared to 7 subjects ( 7/35, 20.0%) in the placebo group.

Post hoc analyses of specific safety evaluations of interest showed adecreased incidence of opioid-related side effects with Formulation Atreatment in Cohort 1. The frequency of the nervous system disorders ofdizziness and somnolence was less in the Formulation A treatment groupscompared to placebo. Specifically, the frequency of dizziness was 64.3%in the placebo group, 27.8% in the Formulation A subaponeurotictreatment group (Treatment 2), and 30.8% in the Formulation Asubcutaneous treatment group (Treatment 1). The frequency of somnolencewas 50.0% in the placebo group, 11.1% in the Formulation Asubaponeurotic treatment group (Treatment 2), and 30.8% in theFormulation A subcutaneous treatment group (Treatment 1). This decreasedincidence of opioid-related side effects correlates with a reduction inopioid use in the Formulation A treatment group compared to placebo.

Conclusions

The primary specified analysis, while numerically better than placebo,did not provide statistical support for the overall hypotheses ofefficacy. The results of the post hoc analyses in Cohort 1 showed thatthe frequency of opioid-related side effects was reduced in theFormulation A treatment groups compared to placebo, which correspondedto a reduction in opioid use in the Formulation A treatment groupscompared to the placebo group. Furthermore, these post hoc analysesshowed a reduction in pain within the first postoperative day in theFormulation A subaponeurotic treatment group compared to the placebogroup, while no difference in pain scores was observed between theFormulation A subcutaneous treatment group and the placebo group.

Example 21

Dissolution profiles were compared from formulations having bupivacainefree base, triacetin, and either poly(lactide-co-glycolide) (PLGA) or apolyorthoester (POE).

In Vitro Dissolution Profile

To compare dissolution profiles, compositions having the same weightpercent bupivacaine and having the same polymer/solvent ratio were madeand tested as described in Exhibit A. As summarized below in Table 21.1,the tested compositions differed in having either apoly(lactide-co-glycolide) (PLGA) having a weight average molecularweight of 16 kDa or a polyorthoester (POE) having a weight averagemolecular weight of 5 kDa.

TABLE 21.1 Composition of each formulation tested PLGA Composition POEComposition Drug (10 wt %) Bupivacaine Bupivacaine Solvent (45 wt %)Triacetin Triacetin Polymer (45 wt %) Poly(lactide-co-glycolide)Polyorthoester (PLGA) (POE) M_(w) = 16 kDa M_(w) = 5 kDa M_(n) = 8 kDaM_(n) = 3 kDa

In vitro release of bupivacaine from the compositions was assessedaccording to the methods described below. FIG. 30 shows the meancumulative release of bupivacaine from the PLGA and POE compositions.

The release from the PLGA composition showed more variability than therelease from the POE composition as shown by the larger error bars(standard deviation) in FIG. 30. The larger variability is also apparentin FIG. 31, which shows the individual release profiles for each of thesix replicates of each formulation. The six replicates involving the POEcomposition are POE1 to POE6, and the six replicates involving the PLGAcomposition are PLGA1 to PLGA6.

Cumulative Release of Bupivacaine In Vitro

The in vitro cumulative release of bupivacaine was determined asfollows.

Materials

The bupivacaine-poly(lactidie-co-glycolide) (PLGA) composition wasprepared as follows. Bupivacaine base was dispersed in triacetin. PLGA(50:50 L:G, M_(w)=16 kDa, M_(n)=8 kDa, initiated with 1-dodecanol) wasadded to the bupivacaine-triacetin mixture. The resulting mixture washomogenized.

The bupivacaine-polyorthoester (POE) composition was prepared asfollows. POE (90:80:20 DETOSU:TEG:TEG-diGL, M_(w)=5 kDa, M_(n)=3 kDa)was mixed with triacetin. The mixture was tumbled for 4.5 hours.Bupivacaine base was added to the triacetin-POE mixture. The resultingmixture was homogenized.

Dissolution Testing—

Dissolution was measured using a USP Apparatus II. Approximately 0.5 mLof each formulation was loaded via cannula and syringed into 900 mL of37±0.5° C. dissolution media (0.025 M sodium phosphate buffer at pH 7.4with 0.03% sodium dodecyl sulfate). The USP Apparatus II was set at 50RPM, and samples were collected at 1, 4, 8, 12, 18, 24, 36, 48, and 72hours and daily afterward. Samples were collected for 5 days and 14 daysfor the POE and PLGA compositions, respectively. Six replicates wereobtained for each composition. The collected samples were assayed forbupivacaine content by HPLC.

The present invention having been thus described, variations andmodifications thereof as would be apparent to those of skill in the artwill be understood to be within the scope of the appended claims.

1-18. (canceled)
 19. A composition comprising: bupivacaine free basepresent in the composition in an amount of 12 wt %, based on weight ofthe composition; sucrose acetate isobutyrate present in the compositionin an amount of 66 wt %, based on weight of the composition; benzylalcohol present in the composition in an amount of 22 wt %, based onweight of the composition; and 2,6-dimethylaniline, wherein the2,6-dimethylaniline is present in the composition at a level less than300 ppm.
 20. The composition of claim 19, wherein the2,6-dimethylaniline is present in the composition in the composition ata level less than 200 ppm.
 21. The composition of claim 19, wherein the2,6-dimethylaniline is present in the composition at a level rangingfrom 0.3 ppm to 200 ppm.
 22. The composition of claim 19, wherein thecomposition further comprises bupivacaine N-oxide.
 23. The compositionof claim 22, wherein the bupivacaine N-oxide is present in thecomposition at a level less than 1 wt %, based on weight of thecomposition.
 24. The composition of claim 22, wherein the bupivacaineN-oxide is present in the composition at a level ranging from 0.01 wt %to 1 wt %, based on weight of the composition.
 25. The composition ofclaim 19, wherein the composition further comprises benzyl acetate. 26.The composition of claim 25, wherein the benzyl acetate is present inthe composition at a level ranging from 0.1 mg/mL to 80 mg/mL.
 27. Thecomposition of claim 19, wherein the composition further comprisesbenzyl isobutyrate.
 28. The composition of claim 27, wherein the benzylisobutyrate is present in the composition at a level ranging from 0.1mg/mL to 40 mg/mL.
 29. The composition of claim 19, wherein when thecomposition is stored in a sealed, upright, clear glass vial at 25°C./60% RH for 36 months, the 2,6-dimethylaniline is present at the levelof less than 300 ppm.
 30. The composition of claim 22, wherein when thecomposition is stored in a sealed, upright, clear glass vial at 25°C./60% RH for 36 months, the bupivacaine N-oxide is present at a levelof less than 1 wt %, based on weight of the composition.
 31. Thecomposition of claim 25, wherein when the composition is stored in asealed, upright, clear glass vial at 25° C./60% RH for 36 months, thebenzyl acetate is present at a level of less than 100 mg/mL.
 32. Thecomposition of claim 27, wherein when the composition is stored in asealed, upright, clear glass vial at 25° C./60% RH for 36 months, thebenzyl isobutyrate is present at a level of less than 50 mg/mL.
 33. Adosage system comprising: a container comprising a first inert material;a closure capable of closing the container, the closure comprising asecond inert material; and the composition of claim 19 contained withinthe container.
 34. The dosage system of claim 33, wherein the secondinert material comprises a fluorinated polymer.
 35. The dosage system ofclaim 33, wherein the first inert material comprises glass that does notcontain iron.
 36. A dosage system comprising: a first container; asecond container within the first container, the second containercomprising a first inert material and the first container reducesambient visible light from irradiating onto the second container; thecomposition of claim 19 within the second container.
 37. The dosagesystem of claim 36, wherein the first container comprises a box.
 38. Acomposition comprising: bupivacaine free base present in the compositionin an amount of 12 wt %, based on weight of the composition; sucroseacetate isobutyrate present in the composition in an amount of 66 wt %,based on weight of the composition; benzyl alcohol present in thecomposition in an amount of 22 wt %, based on weight of the composition;and 2,6-dimethylaniline, wherein the 2,6-dimethylaniline is present inthe composition at a level less than 300 ppm, and wherein thecomposition is sterile.
 39. The composition of claim 38, wherein the2,6-dimethylaniline is present in the composition in the composition ata level less than 200 ppm.
 40. The composition of claim 38, wherein the2,6-dimethylaniline is present in the composition at a level rangingfrom 0.3 ppm to 200 ppm.
 41. The composition of claim 38, wherein thecomposition further comprises bupivacaine N-oxide.
 42. The compositionof claim 38, wherein the composition further comprises benzyl acetate.43. The composition of claim 38, wherein the composition furthercomprises benzyl isobutyrate.
 44. The composition of claim 38, whereinwhen the composition is stored in a sealed, upright, clear glass vial at25° C./60% RH for 36 months, the 2,6-dimethylaniline is present at thelevel of less than 300 ppm.
 45. The composition of claim 41, whereinwhen the composition is stored in a sealed, upright, clear glass vial at25° C./60% RH for 36 months, the bupivacaine N-oxide is present at alevel of less than 1 wt %, based on weight of the composition.
 46. Thecomposition of claim 42, wherein when the composition is stored in asealed, upright, clear glass vial at 25° C./60% RH for 36 months, thebenzyl acetate is present at a level of less than 100 mg/mL.
 47. Thecomposition of claim 43, wherein when the composition is stored in asealed, upright, clear glass vial at 25° C./60% RH for 36 months, thebenzyl isobutyrate is present at a level of less than 50 mg/mL.